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in  the  (Etlg  nf  Nrut  furU 


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THE  CLINICAL  STUDY  OF 
BLOOD-PRESSURE 


THE 

CLINICAL  STUDY  OF 
BLOOD-PRESSURE 

A  GUIDE   TO   THE   USE   OF  THE 

SPHYGMOMANOMETER 

IN  MEDICAL,  SURGICAL,  AND  OBSTETRICAL  PRACTICE,  WITH  A  SUMMARY 

OF  THE  EXPERIMENTAL  AND  CLINICAL  FACTS   RELATING  TO 

THE  BLOOD-PRESSURE  IN  HEALTH  AND  IN  DISEASE 

BY 

THEODORE   C.   JANEWAY,   M.  D. 

LECTURER    ON    MEDICAL    DIAGNOSIS,    UNIVERSITY   AND    BELLEVUE    HOSPITAL 

MEDICAL   COLLEGE,    AND   VISITING    PHYSICIAN   TO 

CITY    HOSPITAL,    NEW    YORK   CITY 


SEVENTY-FIVE  ILLUSTRATIONS  IN  THE    TEXT 
MANY  IN  COLORS 


NEW    YORK    AND    LONDON 

D.    APPLETON    AND    COMPANY 

1904 


Copyright,  1904,  bt 
D.   APPLETON  AND  COMPAKY 


PRINTED  AT  THE  APPLETON  PRESS 
NEW  YORK,  U.   S.    A. 


W  C  7  ^- 
3"  2.  5" 


TO 
MY    FATHER 

MY    BEST    AND    WISEST    TEACHER 

FROM    CHILDHOOD     UNTIL    THIS    DAY 

I    DEDICATE 

WHATEVER    IS    WORTHY 

IN    THIS    BOOK 


402165 


PREFACE 


The  modern  physician's  armamentarium  is  so  complex  that 
additions  to  it  are  far  from  an  unmixed  boon,  Nevertheless, 
the  sphygmomanometer  has  been  welcomed  in  many  quarters 
as  an  instrument  of  real  value.  Two  questions,  however,  must 
be  fairly  and  squarely  answered,  before  its  general  use  can  be 
advocated;  First,  Does  it  yield  accurate  information,  which 
can  be  had  in  no  easier  way  ?  Second,  Is  this  information 
worth  the  time  expended  in  obtaining  it  ? 

The  answer  to  the  first  question  is  simple.  Five  minutes' 
trial  will  convince  the  most  sceptical  that  his  previous  judg- 
ments, based  on  his  supposedly  trained  sense  of  touch,  were 
often  fallacious.  High  tension  was  certainly  recognized  before 
the  introduction  of  the  sphygmomanometer,  but  so  was  fever 
before  the  days  of  chnical  thermometers.  No  physician  would 
endorse  the  sentiments  of  the  old  colored  mammy,  who  said, 
' '  What  you  want  wif  dese  new-f angle  f ermometers,  honey  ? 
I  puts  do  babies  in  de  baf ,  and  if  de  water's  too  cole  it  turns 
'em  blue,  if  it's  too  hot  it  turns  'em  red. "  In  medicine,  accu- 
racy of  observation  is  the  first  step  toward  a  correct  diagnosis, 
without  which  nothing  but  bald  empiricism  is  possible. 

The  second  query  cannot  have  so  prompt  a  reply.  The 
value  of  a  knowledge  of  the  actual  blood-pressure  in  a  par- 
ticular case  must  depend  largely  on  the  observer's  acquaintance 
with  the  physiological  and  pathological  causes  for  variation. 
It  is  the  aim  of  the  author  to  make  this  knowledge,  which  is 
now  scattered  through  text-books  of  physiology,  pathology, 


viii  PREFACE 

and  practice,  and  a  considerable  journal  literature  of  twenty 
odd  years,  readily  available  to  every  practitioner.  With  this 
information,  both  diagnosis,  prognosis,  and  therapeutics  can- 
not but  gain  in  efficiency  through  blood-pressure  determina- 
tions, at  the  bed-side  or  in  the  office. 

His  personal  conviction  of  the  truth  of  this  statement,  after 
the  use  of  various  sphygmomanometers  and  some  critical  study 
of  their  value,  must  be  his  excuse  for  the  presentation  of  this 
book.  In  its  preparation  he  has  incurred  many  obligations, 
which  he  can  only  acknowledge  here  with  hearty  thanks;  to 
his  father.  Dr.  E.  G.  Janeway,  for  most  of  the  opportunities 
for  chnical  study;  to  his  friends.  Prof.  Graham  Lusk,  Drs. 
E.  M.  Evans,  Stuart  Hart,  and  Horst  Oertel,  for  personal 
assistance;  to  Dr.  H.  W.  Cook,  for  his  courtesy  in  allowing 
the  reproduction  of  his  valuable  charts,  and  to  Dr.  J.  Erlan- 
ger,  for  the  mechanical  drawings  of  his  sphygmomanometer. 
In  the  Hterature,  on  the  physiological  side,  the  invaluable 
text-book  of  Tigerstedt;  on  the  technical  side,  the  work  of 
V.  Recklinghausen,  of  Gumprecht,  and  of  Vaschide  and  Lahy ; 
and  in  the  clinical  portion,  the  articles  of  Cook  and  Briggs, 
Hensen,  and  Cushing,  and  Crile's  studies,  have  been  of  the 
greatest  service.  He  would  also  thank  Drs.  Province,  W.  C. 
Garvin  Higgins,  A.  H.  Garvin,  Chapin,  Boyd,  and  Garside, 
of  the  House  Staff  of  City  Hospital,  for  their  aid  and  coopera- 
tion in  obtaining  illustrative  charts,  and  Mr.  Ed.  Ruschli  and 
Mr.  Max  Jiitte,  of  the  second  year  class  at  the  University 
and  Bellevue  Hospital  Medical  College,  the  former  for  mano- 
metric  tracings,  the  latter  for  aid  in  preparing  part  of  the 
bibliography.  The  excellent  drawings  of  apparatus  are  by 
Mr.  K.  K.  Bosse. 

T.  C.  J. 

36  West  Foetieth  Steeet. 


TABLE   OF  CONTENTS 


PART  I.— PHYSIOLOGICAL 

CHAPTER  PAGE 

I. — The  direct  measurement  of  blood-pressure 1 

1.  Introduction — The  mercurial  manometer 3 

2.  The  normal  manometric  trace 4 

3.  The  errors  of  the  mercurial  manometer — Compensated  manometer  5 

4.  Elastic  manometers — Maximum  and  minimum  manometers. 


ood -pressure 


7 
9 
11 
28 
30 
32 
37 
37 
38 
39 


II. — Blood-pressure  in  the  normal  animal    . 

1.  General  features  of  the  arterial  circulation 

2.  The  factors  which  determine  blood-pressure  . 

3.  The  mean  aortic  blood-pressure  in  different  anima' 

4.  The  blood- pressure  in  different  arteries  . 

5.  The  periodic  variations  of  aortic  blood-pressure 

6.  Spontaneous  non-rhythmical  variations  of  aortic  b 

7.  The  influence  of  asphyxia  on  blood-pressure  . 

8.  The  influence  of  atmospheric  pressure  on  blood-pressure 

9.  The  influence  of  muscular  work  on  blood-pressure 

PART  II.— TECHNICAL 

III. — The  indirect  measurement  of  blood-pressure      ....  41 

1.  Introduction 43 

2.  The  development  of  sphygmomanometers  applying  pressure  to 

the  artery  through  a  fluid  medium 46 

3.  The  method  of  circular  compression  by  air 54 

4.  Experimental  verification  of  the  method  of  circular  compression.  55 

5.  Validity  of  the  several  eriteria 62 

IV. — The  modern  sphygmomanometers 75 

1.  Introduction 77 

2.  Instruments  measuring  systolic  pressure  only         ....  77 

3.  Instruments  measuring  diastolic  pressure 84 

4.  Instruments   measuring  systolic   pressure  and  affording  an  ap- 

proximate estimate  of  diastolic  pressure 87 

5.  Instruments   measuring  accurately  both  systolic   pressure  and 

diastolic  pressure  by  graphic  record 93 

6.  Comparison  of  results  obtained  with  the  various  sphygmoma- 

nometers        100 

7.  Blood-pressure  records 101 

8.  Practical  suggestions 102 

ix 


TABLE   OF   CONTENTS 


PART  III.— CLINICAL 

CHAPTER 

V. — Blood-pressure  in  the  normal  man 

1.  General  considerations 

2.  Blood-pressure  in  different  individuals 

3.  Blood-pressure  variations  in  the  same  individual 
Literature 


VL — The  blood-pressure  in  disease      .... 

1.  Pathological  limits  of  blood-pressure    . 

2.  High  blood-pressure  (hypertension) 

3.  Low  blood-pressure  (hypotension) 

4.  The  relation  of  blood-pressure  to  pulse-rate  and  temperature 

5.  Blood-pressure  as  a  guide  to  the  functional  ability  of  the  lieart 

and  the  adequacy  of  the  circulation 
Literature 


VII. — Blood-pressure  in  internal  diseases    . 

1.  Diseases  of  the  heart,  arteries,  and  kidneys. 

Literature 

Acute  infectious  diseases       ..... 

Chronic  infectious  diseases 

Clironic  diseases  associated  with  impaired  nutrition 

Miscellaneous 

Literature 


VIII. — Blood-pressurk  in  nervous  and  mental  diseases 

1.  Diseases  of  the  spinal  cord    . 

2.  Diseases  of  the  brain 

3.  The  psychoses         .... 

4.  Functional  conditions    . 
Literature       ."       . 


IX. — Blood-pressure  in  surgical  conditions 

1.  Uses  of  the  sphygmomanometer  in  surgical  practice 

2.  Blood-pressure  during  surgical  operations    . 

3.  Blood-pressure  in  surgical  accidents  and  diseases 
Literature 


X.- 


-Blood-itiessure  in  obstetrical  conditions    . 

1.  Value  of  the  sphygmomanometer  in  obstetrical  practice 

2.  Blood-pressure  during  pregnancy 

3.  Blood-pressure  during  labor  and  the  puerperium 

4.  Puerperal  eclampsia 

Literature 


LIST  OF  ILLUSTEATIONS 


FIGURE  PAGE 

1.  Tracing. — The  normal  manometric  trace 5 

2.  Diagram. — The  flow  of  liquid  through  tubes 10 

3.  Tracing. — Fall   in   blood-pressure   produced  by  stimulation   of   the 

peripheral  cut  end  of  the  vagus 12 

4.  Tracing. — Fall  in  blood-pressure  produced  by  stimulation  of  the  cen- 

tral cut  end  of  the  vagus  (depressor  eflfeet)      ...  20 

5.  Tracing. — Rise  in  blood-pressure  produced  by  stimulation  of  the  ante- 

rior crural  nerve  (pressor  effect)      .....  21 

6.  Tracing. — Fall  in  blood-pressure  produced  by  haemorrhage  ...  27 

7.  Cut. — V.  Basch's  sphygmomanometer.     First  model       ....  46 

8.  Cut. — V.  Basch's  sphygmomanometer.     Recent  model   ....  47 

9.  Cut. — Potain's  sphygmomanometer 48 

10.  Cut. — Marey's  second  sphygmomanometer     .        .        .        ....  51 

11.  Cut. — Mosso's  sphygmomanometer .52 

12.  Diagram. — Cross-section  of  arm,  Riva-Rocci  armlet      .        .        .        .  54 

13.  Diagram. — Cross-section  of  arm,  Hill  and  Barnard  armlet   ...  54 

14.  Diagram. — Cross-section  of  finger  with  Gartner  ring    ....  55 

15.  Diagram. — Distortion  of  a  tube  by  blocks  laid  on  it      .        .        .        .57 

16.  Diagram. — Manner  of  closure,  normal  and  sclerotic  artery  ...  60 

17.  Tracing. — Tracings  from  the  forearm,  illustrating  the  return  of  the 

pulse  under  compression 63 

18.  Tracing. — The  pulsations  transmitted  through  an  elastic  membrane 

separating  two  vessels 70 

19.  Diagram. — Apparatus  of  Walden  for  verifying  the  criterion  of  maxi- 

mum pulsation  of  the  arterial  wall 71 

20.  Tracing. — Normal  pulse,  Erlanger's  sphygmomanometer      .        .        .72 

21.  Cut. — Riva-Rocci's  sphygmomanometer 79 

22.  Cut. — Cook's  sphygmomanometer    .        . 81 

23.  Cut. — Gartner's  tonometer 83 

24.  Cut. — Hill  and  Barnard's  sphygmometer 85 

25.  Cut. — Stanton's  sphygmomanometer 88 

26.  Cut. — Author's  sphygmomanometer 90 

37.  Cid. — Erlanger's  sphygmomanometer .  94 

28.  Cut. — Erlanger's  sphygmomanometer,  stop-cock  from  above         .        .  95 

29.  Cut. — Erlanger's  sphygmomanometer,  section  of  stop-cock,  position 

"IN" 96 

xi 


xii  LIST   OF   ILLUSTRATIONS 

FIGDRB  PAGE 

30.  Cut. — Erlanger's  sphygmomanometer,  section  of  stop-cock,  position 

"OUT" 97 

31.  Cm^.— Erlanger's  sphygmomanometer,  section  of  stop-cock,  position  1  97 

32.  Tracing. — High  tension  pulse,  Erlanger's  sphygmomanometer     .        .  99 

33.  Chart. — Illustrating  manner  of  recording  blood-pressure,  pulse,  and 

respiration.     Case  of  lobar  pneumonia    .        .     Facing  102 

34.  Tracing. — Periodic  fluctuations  of  blood-pressure,  healthy  man  .        .  113 

35.  Chart. — Diurnal  blood-pressure  chart  of  a  healthy  man        .        .        .  114 

36.  Chart. — Diurnal  variations  of  diastolic  pressure,  the  influence  of  meals 

being  excluded 115 

37.  Chart. — Rise  in  blood-pressure  produced  by  tobacco      ....  118 

38.  Chart. — Rise  in  blood-pressure  produced  by  mental  effort    .        .        .  120 

39.  Chart. — Rise  in  blood-pressure  produced  by  muscular  exertion    .        .  121 

40.  Chart. — Influence  of  muscular  exertion  on  blood-pressure  in  the  aged  123 

41.  Chart. — Influence  of  water-baths  of  different  temperatures  on  blood- 

pressure  and  pulse-rate 125 

42.  Chart. — Marked  hypertension  in  chronic  interstitial  nephritis      .        ,  170 

43.  Chart. — Chronic  nephritis ;  left  hemiplegia;  lobar  pneumonia;  death  174 

44.  Chart. — Chronic  urjemia 180 

45.  Chart. — General  arterio-sclerosis 186 

46.  Tracing. — Pulsus  differens.     Case  of  obstruction  of  the  left  axillary 

artery 190 

47.  Chart. — Aortic  insufficiency 196 

48.  Chart. — Terminal  hypotension  in  cardiac  disease 199 

49.  C/(ar^— CEdema  of  the  lungs 206 

50.  Cm^— Dehio's  apparatus 209 

51.  Chart. — Fall  in  blood-pressure  produced  by  nitroglycerin,  gr.  xoo        •  211 

52.  Chart. — Fall  in  blood-pressure  produced  by  nitroglycerin,  gr.  ^ .        .  212 

53.  Chart. — Typhoid  fever  (showing  effect  of  baths) 218 

54.  Chart. — Typhoid  fever — intestinal  hfemorrhage 219 

55.  Chart. — Typhoid  fever — intestinal  perforation 220 

56.  Chart. — Typhoid  fever  with  toxaemic  features  and  hypotension  (show- 

ing effect  of  digitalin) 222 

57.  Chart. — Absence  of  any  rise  in  blood-pressure  after  the  subcutaneous 

injection  of  adrenalin 223 

58.  Chart. — Extreme  rise  in  blood-pressure  produced  by  the  intravenous 

injection  of  adrenalin 224 

59.  Chart. — Fatal  lobar  pneumonia 228 

60.  Chart. — Marked  hypotension  in  acute  tuberculosis        ....  232 

61.  Cliart. — Chronic  pulmonary  tuberculosis  with  slight  hypotension         .  233 

62.  Chart. — Intracranial  hu'morrhage  (apoplexy)  with  exploration  of  the 

brain  and  evacuation  of  a  large  clot        ....  250 

63.  Chart. — Relation  between  blood -pressure  and  psychical  state  in  melan- 

cholia          254 

64.  Chart. — Average  curves  of  blood-pressure  during  anaesthesia        .        .  262 

65.  Chart. — Thoracotomy  for  post-pneumonic  empyema  under  local  cocain 

anesthesia 264 


LIST   OF   ILLUSTRATIONS  xiii 

FIGURE                                                                                                                                                                            -  PAGE 

66.  Chart. — Excision  of  hydrocele  sac  after  spinal  cocainization         .        .  265 

67.  Chart. — Forcible  stretching  of  left  sciatic  nerve  for  sciatica         .        .  266 

68.  Chart. — Operation  for  osteomyelitis  of  femur 267 

69.  Chart. — Laparotomy  (appendectomy) 268 

70.  Chart. — Cholecystectomy Facing  269 

71.  Chart. — Laparotomy  for  uterine  fibroids 270 

72.  Chart. — Prostatectomy Facing  272 

73.  Chart. — Traumatic  shock  without  haemorrhage 274 

74.  Chart. — Post-operative  depression  (twin  labor) 286 

75.  Chart. — Puerperal  eclampsia 288 


ABBEEVIATIONS  USED 


(v.  B.)  =  V.  Basch's  sphygmomanometer  (see  page  46). 
(Erl.)  =  Erlanger's  sphygmomanometer  (see  page  93). 
(G.)  =  Gartner's  tonometer  (see  page  82). 
(H.  &  B.)  =  Hill  and  Barnard's   sphygmometer  (see  page  84). 
(J.)  =  Author's  sphygmomanometer  (see  page  89). 
(Mosso)  =  Mosso's  sphygmomanometer  (see  page  51). 
(P.)  =  Potain's  sphygmomanometer  (see  page  48). 
(R.  R.)  =  Riva-Rocci's  sphygmomanometer,  or  Cook's  modi- 
fication (see  pages  78  and  80). 

(5  cm.),' (13  cm.),  etc.,  refer  to  the  width  of  compressing  sur- 
face in  the  armlet  used. 

(1.5  cm.)  or  (2.5  cm.)  refer  to  the  -width  of  compressing  surface 
in  the  Gartner  ring  used. 

Sys.  =  Systolic  end  pressure. 
Diast.  =  Diastolic  lateral  pressure. 


PART  I.— PHYSIOLOGICAL 


CHAPTER  I 

THE  DIRECT   MEASUREMENT  OP  BLOOD-PRESSURE 

1.  Introduction. 

A.  The  mercurial  manometer. 

B.  The  kymographion. 

2.  The  normal  manometric  trace. 

3.  The  errors  of  the  mercurial  manometer — Compensated  manometer. 

4.  Elastic  manometers — Maximum  and  minimum  manometers. 


CHAPTER  I 

THE  DIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

1.    INTRODUCTION 

That  the  blood  exerts  pressure  upon  the  vessels  through 
which  it  circulates  is,  of  course,  a  necessary  corollary  of  the 
fact  that  it  flows ;  but  more  than  a  hundred  years  elapsed  be- 
fore Harvey's  discovery  of  the  circulation  was  followed  by 
Hales's^  demonstration  of  the  blood-pressure,  in  1733,  and  a 
second  century  before  its  accurate  study  was  begun. 

A.  The  Mercurial  Manometer. — The  exact  determinations 
which  mark  the  beginning  of  modern  physiological  experi- 
ment took  their  origin  with  two  men,  Poiseuille  and  Ludwig. 
The  former,  in  1828,^  introduced  the  mercurial  manometer  of 
U  form,  thus  bringing  the  observation  of  blood-pressure  within 
the  compass  of  a  reasonable  space,  and,  in  addition,  made  pro- 
longed experiments  possible  for  the  first  time,  by  retarding  the 
coagulation  of  the  blood  in  the  tube  leading  from  the  artery. 
This  he  accomplished  by  filling  the  tube  with  a  saturated 
solution  of  sodium  carbonate,  which  is  commonly  employed  to 
this  day. 

B.  The  Kymographion. — Ludwig's  contribution  was  of  even 
greater  importance,  because  the  graphic  method,  which  he  ap- 
plied to  the  study  of  the  blood-pressure  in  1847,^  has  proved 
not  alone  a  means  of  permanent  and  unimpeachable  record, 
but  an  invaluable  aid  in  the  elucidation  of  all  the  mechanical 
problems  of  physiology.     To  his  kymographion  we  owe  nearly 

'  Hales,  Stephen.  Statical  Essays:  containing  Hfemastatics.  London, 
1733,  vol.  ii,  pp.  1  and  following. 

*  Poiseuille,  I.  L.  M.  Reeherches  sur  la  force  dii  coeur  aortique.  Paris, 
1828,  pp.  23  and  following.  Quoted  by  Tigerstedt,  Lehrbuch  d.  Physiol,  des 
Kreislaufes,  Leipzig,  1893,  p.  822. 

*  Ludwig,  C.  Beitrage  zur  Kenntnis  des  Einflusses  der  Respirationsbeweg- 
ungen  auf  den  Blutdruck  im  Aortetisysteme.  Arch.  f.  Anatomic,  Physio- 
logie  u.  Wissenschaftliche  IMod.,  etc.,  1847,  p.  261  and  following. 

3 


4     DIRECT   MEASUREMENT   OF   BLOOD-PRESSURE 

all  our  accurate  knowledge  of  the  circulation.  This  method  of 
obtaining  a  blood-pressure  tracing,  by  a  recording  manometer 
connected  directly  with  an  opened  artery  and  writing  upon  a 
revolving  cylinder,  is  so  familiar  as  to  need  no  explanation  here. 
That  this  method  does  not  give  an  accurate  record  of  all 
the  events  within  the  artery  is  not  so  well  known,  and  is 
scarcely  mentioned  in  the  current  text-books  on  physiology, 
because  these  confine  themselves  to  the  discussion  of  mean 
blood-pressure.  The  clinical  methods  for  investigating  blood- 
pressure,  however,  never  determine  the  mean  pressure,  but 
either  the  maximum  (systolic)  or  minimum  (diastolic),  and 
much  confusion  has  arisen  through  a  lack  of  appreciation  of 
this  fact.  At  the  outset,  therefore,  everyone  who 
would  intelligently  use  these  clinical  instru- 
ments should  understand  the  manometric  blood- 
pressure  trace  and  its  limitations. 

2.    THE  NORMAL  MANOMETRIC  TRACE 

Such  a  tracing  is  shown  in  Fig.  1.  Two  distinct  sets  of 
fluctuations  are  apparent  in  it.  A  careful  comparison  with 
a  simultaneous  record  of  the  movements  of  the  chest  would 
show  that  the  larger  and  more  gradual  rises  and  falls  corre- 
spond with  expiration  and  inspiration  respectively;  the  small 
and  rapid  oscillations  are  those  due  to  systole  and  diastole  of 
the  ventricles  of  the  heart.  With  a  rapidly  revolving  cylinder 
these  pulse-waves  may  be  more  easily  followed ;  but  this  is  not 
desirable  for  the  determination  of  blood-pressure.  It  is  evi- 
dent from  this  tracing  that  the  arterial  blood-pressure  is  not  a 
constant  quantity,  susceptible  of  easy  measurement,  even  for 
a  short  period  of  time,  but,  under  the  conditions  of  this  experi- 
ment, has  a  certain  average  level  about  which  it  fluctuates 
rhythmically.  This  average  height  of  the  curve  above  the 
base-line  of  atmospheric  pressure  may  be  easily  calculated  for 
any  given  period  of  time,  and,  when  multiplied  by  2,'  gives 
an  exact  measure  in  mm.  Hg.  of  the  average  or  mean  blood- 
pressure. 

'  In  all  accurate  U-tube  manometers  the  displacement  of  the  surface  of  the 
mercury  in  the  two  arms  is,  of  course,  equal  in  amount,  but  opposite  in  direc- 
tion ;  therefore  the  height  of  the  column  is  twice  as  great  as  the  movement  in 
the  open  arm. 


THE  MERCURIAL  MANOMETER  5 

3.  THE  ERRORS  OF  THE  MERCURIAL  MANOMETER 
-COMPENSATED   MANOMETER 

So  heavy  a  liquid  as  mercury  cannot  possibly  follow  the 
rapid  cardiac  and  respiratory  variations  in  pressure,  and  it  is 
to  be  emphasized  that  the  extent  of  these  on  the  manometric 
trace  affords  no  measure  of  their  actual  value.  Even  for  the 
accurate   determination  of  mean  pressure,  certain  conditions 


Fig.  1. — Normal  manometric  trace. 
From  the  carotid  of  a  dog. 

are  necessary,  the  most  important  of  which  is  the  calibre  of 
the  tube.  v.  Kries  ^  found  that  a  manometer  of  4  mm.  diam- 
eter gave  readings  which  did  not  vary  more  than  three  per 
cent,  from  the  actual  mean  pressure,  when  the  pressure  was 
subjected  to  rapid  variation,  as  in  blood-pressure  experiments. 
He  advocated   a  constriction  of  the    tube  leading   from  the 

*  V.  Kries,  Dr.  Ueber  die  Bestimraung  des  Mitteldruckes  durch  das 
Quecksilbermanometer.  Arch.  f.  Anatomie  u.  Physiologie,  Physiologische 
Abtheilung,  1878,  pp.  430  and  following  and  p.  440, 


6     DIRECT   MEASUREMENT   OF   BLOOD-PRESSURE 

artery,  which  almost  obhterates  the  pulse  wave  in  the  ma- 
nometer, and  Marey  ^  constricted  the  manometer  itself  at  one 
point,  calling  his  instrument  a  compensated  one.  Such  in- 
struments require  five  seconds  to  reach  the  true  level,  but  then 
give  exact  readings  of  mean  pressure. 

4.    ELASTIC   MANOMETERS-IVIAXIIVIUM   AND 
MINIMUM    MANOMETERS 

For  most  of  the  purposes  of  physiological  and  pharmaco- 
logical experiment,  a  knowledge  of  the  changes  in  mean 
blood-pressure  has  been  considered  sufficient.  Attempts  have 
been  made,  however,  to  study  quantitatively  the  cardiac  vari- 
ations by  means  of  elastic  manometers  of  more  or  less  compli- 
cated construction,  such  as  are  used  to  record  intracardiac 
changes.  Chaveau  and  Marey,  Fick,  Hiirthle^  and  others 
have  worked  in  this  field,  some  using  air  and  some  water  in 
transmitting  the  vibrations,  and  quite  a  controversial  literature 
has  grown  up  over  the  accuracy  of  the  respective  vehicles,  so 
that  none  of  their  results  can  be  considered  as  having  absolute 
value.  When  controlled,  however,  by  readings  of  maximum 
and  minimum  pressures  during  short  periods,  taken  by  means 
of  mercurial  manometers  fitted  with  valves  so  as  to  record 
only  maximum  or  minimum  pressures,  they  probably  give  us 
a  fair  insight  into  the  systolic  and  diastolic  fluctuations  of 
blood-pressure,  and  a  criterion  by  which  we  may  judge  the 
validity  of  our  clinical  approximations. 

These  methods,  all  measuring  directly  the  pressure  within 
an  opened  artery,  are  obviously  inapplicable  to  the  study  of 
the  subject  in  man,  or  even  in  animals,  except  under  certain 
fixed  conditions.  Their  results,  however,  must  always  be  the 
starting-point  for  any  extension  of  our  knowledge.  For  this 
reason,  it  seems  to  mo  necessary  to  consider  some  important 
features  of  the  arterial  circulation,  as  it  has  been  elucidated 
under  the  simpler  conditions  of  physiological  investigation, 
before  turning  to  the  complex  problems  of  the  indirect  estima- 
tion of  human  blood-pressure  in  health  and  disease. 

'  Marey.  Annales  des  sciences  naturelles.  4'  serie,  Zoologie,  vol.  viii,  1858, 
p.  350.     Quoted  by  Tigerstedt,  p.  325. 

^  See  Tigerstedt,  K.  Lehrbuch  d.  Piiysiol.  des  Kreislaufes,  Leipzig,  1893, 
pp.  83-89. 


CHAPTER  II 

BLOOD-PRESSURE  IN  THE  NORMAL  ANIMAL 

1.  General  features  of  the  arterial  circulation. 

A.  The  flow  of  liquid  through  tubes. 

2.  The  factors  which  determine  blood-pressure. 

A.  The  energy  of  the  heart. 

Influence  on  blood-pressure  of  volume  output  and  of  rate. 

Influence  of  blood-pressure  on  rate  ;  the  depressor  mechanism ;  on 

volume  output. 
Influence  of  intra-abdominal  pressure  on  blood-pressure. 

B.  The  peripheral  resistance. 
The  vaso-motor  tone. 

Its  presence  in  veins  as  well  as  arteries. 
Vaso-coiistrictor  nerves  and  centres. 

Necessity  of  the  vaso-motor  tone  for  the  maintenance  of  the  circu- 
lation. 
The  vaso-dilator  flbres. 

Local  and  general  variations  in  vaso-motor  tone. 
The  vascular  reflexes. 
The  depressor  nerve. 
Pressor  and  depressor  fibres. 
Importance  of  the  splanchnic  circulation. 
Relation  between  different  vascular  areas. 

C  The  elasticity  of  the  arterial  wall. 

The  distensibility  of  the  arteries  and  their  resistance  to  strain. 
The  variation  of  elasticity  with  internal  pressure. 

D.  The  volume  of  circulating  blood. 

Smallness  of  the  blood-volume  contrasted  with  the  capacity  of  the 

relaxed  vascular  system. 
Effect  of  great  diminution  in  blood-volume  on  mean  pressure  only 

temporary. 
Insignificant  effect  of  increased  volume. 
Relation  of  systolic,  diastolic,  and  mean  pressure  after  hjemorrhage. 


8     BLOOD-PRESSURE   IN   THE   NORMAL  ANIMAL 

3.  The  mean  aortic  blood-pressure  in  different  animals. 

A.  Direct  determinations  of  human  blood-pressure. 

4.  The  blood-pressure  in  different  arteries. 

6.  The  periodic  variations  of  aortic  blood-pressure. 

A.  The  cardiac  variations.      SystoUc  and  diastolic  pres- 

sures. 

B.  The  respiratory  variations. 

C.  The  Traube-Hering  waves. 

6.  Spontaneous  non-rhythmical  variations  of  aortic  blood-pressure. 

7.  The  influence  of  asphyxia  on  blood-pressure. 

8.  The  influence  of  atmospheric  pressure  on  blood-pressure. 

9.  The  influence  of  muscular  work  on  blood-pressure. 


CHAPTER  II 

BLOOD-PRESSURE   IN  THE  NORMAL  ANIMAL 

1.  GENERAL  FEATURES  OF  THE  ARTERIAL 
CIRCULATION 

At  the  centre  of  the  circulation  works  the  heart,  pumping 
the  blood  from  the  veins  into  the  great  arteries,  the  ventricles 
first  filling,  then  in  a  shorter  time  discharging  their  contents 
with  great  velocity ;  then  resting  to  receive  the  next  charge, 
and  again  to  empty  themselves,  in  rhythmic  sequence.  At  the 
periphery,  with  quiet,  even  flow,  the  blood-stream  in  the  vast 
capillary  areas  moves  slowly  toward  the  veins,  everywhere 
flooding  the  tissues  with  nutriment  and  oxygen.  From  heart 
to  capillaries  the  blood  is  carried  by  the  arteries,  continually 
branching  from  the  largest  trunks  to  the  smallest  arterioles, 
and  within  their  walls  this  wonderful  transformation  of  an 
intermittent  jet  into  a  continuous  flow  takes  place.  It  is  evi- 
dent, then,  that  they  are  not  mere  conducting  tubes,  like  so 
many  water  pipes,  but  that  they  exert  a  powerful  influence 
upon  the  blood-current.  For  the  better  understanding  of  this 
function  of  the  arteries,  and  of  the  causes  of  the  arterial  blood- 
pressure,  we  must  turn  to  certain  facts  concerning  the  flow  of 
liquid  through  tubes. 

A.  The  Flow  of  Liquid  through  Tubes.— Since  Hquids  are 
almost  incompressible,  it  is  clear  that  an  intermittent  flow 
through  rigid  tubes  must  always  be  the  same  at  all  points,  and 
exactly  the  same  amount  must  leave  the  tube  as  enters  it. 
With  distensible  tubes  of  elastic  material,  such  as  the  arterial 
walls,  the  conditions  are  different.  If  the  tube  be  short  and 
the  calibre  large  in  proportion  to  the  size  of  the  pump  used,  the 
walls  may  not  be  put  appreciably  on  the  stretch  and  an  inter- 
mittent flow  will  occur,  much  as  in  a  rigid  tube.  If,  however, 
a  larger  tube  be  used  and  the  open  end  narrowed  to  create  a 

9 


10  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 


resistance  to  the  outflow,  with  the  first  injections  Httle  fluid 
will  leave  the  tube,  the  bulk  accumulating  within  and  distend- 
ing it.  This,  of  course,  raises  the  pressure,  which  in  turn  in- 
creases the  outflow,  so  that,  as  the  experiment  continues,  the 
flow  gradually  increases  until  a  steady  stream  is  delivered, 
which  just  equals  the  amount  pumped  in  during  the  same 


Fig.  2. — Diagram  illosthating  the  flow  of  liquid  through  tubes. 


time.  When  this  point  is  reached  the  system  is  in  equilibrium, 
and  the  amount  of  distention  of  the  tube  and  the  pressure  will 
bear  an  exact  relation  to  the  volume  of  intake  and  the  size  of 
the  outlet. 

Such  an  experiment  is  shown  in  Fig.  2.  If  we  connect  a 
manometer  (A)  with  the  end  of  the  tube  we  can  measure  the 
Total  or  End  Pressure  at  that  point.  If,  at  some  other 
point,  a  T-canula  (B)  be  introduced  without  obstructing  the 
flow  and  a  manometer  (C)  connected  with  it,  a  pressure  will 
be  registered  slightly  lower  than  the  end  pressure.  This  is  the 
Lateral  Pressure,  and  is  the  force  exerted  on  the  walls 
of  the  tube  at  that  point.  The  dift'erence  between  it  and  the 
end  pressure  is  due  to  the  fact  that  the  latter  contains  the 
pressure  duo  to  the  velocity  of  the  stream  in  addition.  If  the 
outlet  be  widened  or  the  rate  of  the  pump  diminished,  the  lat- 
eral pressure  will  be  seen  to  fall.  Should  this  be  continued 
j)r()grossively,  a  point  will  be  reached  at  which  the  outflow  will 
again  become  intermittent  and  lateral  pressure  will  only  be 
evident  at  each  stroke  of  the  pump. 

Those  exjjoriments  ])7-ove  that  two  coiiditions  must  be  pres- 
ent to  account  for  the  disappearance  of  Iho  pulse  wave  in  the 


FACTORS   DETERMINING   BLOOD-PRESSURE    11 

normal  arterial  circulation :  they  are,  the  elasticity  of  the  arte- 
rial wall,  and  resistance  to  the  flow,  which  we  speak  of  as  the 
peripheral  resistance.  They  show  in  addition  that,  at  any 
given  point  of  the  arterial  system,  the  blood  must  exert  a  pres- 
sure against  the  arterial  wall,  which  we  may  measure  through 
a  T-canula  introduced  into  the  artery,  and  a  total  pressure, 
which  will  equal  the  side  pressure  plus  the  velocity  of  the 
stream,  and  is  recorded  when  we  attach  a  manometer  to  a 
straight  canula  within  the  artery.  As  the  common  carotid 
artery  leaves  the  aorta  at  practically  a  right  angle,  the  end 
pressure  within  it  gives  the  lateral  pressure  within  the  aorta. 

As  the  scope  of  this  book  does  'not  include  the  capillary 
and  venous  circulations,  whenever  subsequently  blood-pressure 
is  referred  to,  it  is  understood  that  arterial  blood-pressure  is 
meant. 

2.    THE    FACTORS    WHICH    DETERMINE    BLOOD- 
PRESSURE 

In  any  individual,  the  blood-pressure  at  a  given  moment 
depends  upon  four  separate  factors :  a.  the  energy  of  the 
heart;  b.  the  peripheral  resistance;  c.  the  elas- 
ticity of  the  arterial  walls;  d.  the  volume  of 
circulating  blood.  These  may  aU  vary  under  normal 
conditions,  and  in  pathological  states  become  greatly  altered. 
Not  only  do  they  vary  independently  of  one  another,  but  so 
close  is  their  connection,  especially  through  the  vaso-motor  and 
cardiac  nervous  mechanisms,  that  changes  in  certain  of  them 
may  produce  marked  secondary  effects  upon  the  others.  For 
this  reason  the  necessary  conditions  of  experimental  study  are 
difficult  and  the  results  conflicting,  so  that  our  knowledge,  even 
of  the  normal  circulation,  is  incomplete,  and,  when  it  is  applied 
to  the  still  more  complicated  phenomena  of  disease,  is  most 
inadequate.  Nevertheless,  it  is  of  the  utmost  importance  that 
our  clinical  concepts  and  theories  be  built  only  upon  the  firm 
foundation  of  established  fact,  even  though  we  might  wish  the 
foundation  more  ample. 

A.  The  Energy  of  the  Heart. — That  the  heart  is  the  original 
source  of  all  the  forms  of  energy  which  we  find  manifested  in 
the  circulation  is  obvious.  The  blood-pressure  necessarily  de- 
pends in  the  first  instance  upon  the  force  of  ventricular  systole. 


12   BLOOD-PRESSURE  IN   THE   NORMAL  ANIMAL 


Since  the  work  of  the  heart  depends  upon  the  volume  of  blood 
discharged  into  the  aorta,  the  velocity  imparted  to  it,  and  the 

aortic  pressure  overcome,  it  is 
plain  that  a  difference  in  blood- 
pressure  may  be  brought  about 
by  change  in  either  the  vol- 
ume output  or  the  velocity  of 
discharge. 

Any  increase  in  the 
volume  output  of  the 
ventricles  causes  a  rise 
in  pressure,  and  any 
diminution  a  fall,  if  the 
peripheral  resistance 
remains  unchanged. 
Such  increase  may  be  brought 
about  in  three  ways:  either 
by  a  larger  systolic  pulse-vol- 
ume, or  by  a  greater  number 
of  systoles  per  minute,  or  by 
both  combined.  The  fall  of 
blood-pressure  which  follows 
strong  stimulation  of  the  vagi 
peripherally  is  produced  by 
both  slowing  the  heart  and 
decreasing  the  systolic  output ; 
and  the  two  most  commonly  coincide.  Such  a  fall  in  pressure, 
with  marked  decrease  in  ventricular  output  and  slowing  of  the 
heart,  is  beautifully  illustrated  by  a  tracing  of  Porter's  *  from 
an  experiment,  in  which  the  diminished  cardiac  energy  fol- 
lowed tying  off  the  circumflex  branch  of  the  coronary  artery 
in  a  dog. 

Rate  and  volume  do  not  necessarily  follow  one  another, 
however,  for  both  Woolridge '  and  Pawlow,^  by  the  stimulation 

'  Porter,  W,  T.  Further  Researches  on  the  Closure  of  the  Coronary  Arte- 
ries. Journal  of  Expcr.  Med.,  1896,  vol.  i,  p.  51 ;  also,  Amer.  Text-Book  of 
Phy.siol.,  second  edition,  1900,  vol.  i,  p.  182. 

'  Woolridge,  Leonard.  Ueber  die  Function  der  Kammernerven  des  Saiige- 
thierhcrzens.  Arch.  f.  Anatomic  u.  Physiologic,  Abthcilung  f.  Physiologie, 
1883,  p.  587. 

'  Pawlow,  I.  P.     Ueber  den  Einfluss  dcs  Vagus  auf  die  Arbeit  der  linken 


Fig.  3. — Fall  in  blood-piiessure  tro- 
dl'ced  by  stimulation  of  the  periph- 
eral cut  end  of  the  vagus. 

Trace  from  dog's  carotid.    Tetauizing  cur- 
rent. 


FACTORS   DETERMINING   BLOOD-PRESSURE    13 

of  certain  augmentor  nerve  branches  in  dogs,  obtained  increase 
in  pulse  volume  and  rise  in  pressure  without  change  in  fre- 
quency.    This  was  probably  due  to  greater  suddenness  of  con- 
traction, allowing  a  longer  diastolic  period  for  the  filling  of  the 
ventricle.     Vice- versa,  increased  rate  does  not  always  raise 
pressure.     Miinzel^  demonstrated  this  most  clearly.     Having 
first  severed  the  spinal  cord  to  eliminate  all  vaso-motor  influ- 
ences, he  stimulated  the  accelerator  nerve  and,  in  spite  of  the 
extreme  rise  in  rate,  the  change  in  pressure  was  insignificant. 
For    greater    frequency    to    raise    pressure    there 
must   be   a    large   amount    of    blood    in    the    great 
veins  awaiting  entrance  to  the  heart,  and  a  suf- 
ficient  peripheral  resistance.     O.  Frank ^  holds  that, 
under  normal  conditions,  pure  rate  variation  (excluding  any 
dynamic  change  in  the  heart)  has  such  a  relation  to  volume 
output,   that  the  latter  is  greatest  at  a  moderate  rate,   and 
hence,  this  gives  the  highest  blood-pressure;   that  a  change 
either  way  results  in  lower  pressure;   but  within  reasonable 
limits,  difference  in  rate  has  slight  effect  on  pressure. 

The  relation  between  cardiac  energy  and  blood-pressure  is  a 
double  one,  however,  and  variations  in  the  latter  have  a  con- 
siderable influence  on  the  heart.  In  the  normal  animal  the 
pulse  rate  is  slowed  by  raising  arterial  pressure,  and  hastened 
by  lowering  it,  as  Marey^  first  proved.  Since  this  does  not 
as  a  rule  occur  after  division  of  the  vagi,  it  is  evidently  due  to 
action  on  the  vagus  centre,  the  more  so,  since,  the  majority  of 
observers  agree  that  variations  in  pressure  have,  of  themselves, 
little  effect  on  the  isolated  heart.  *  This  action  is  in  part  reflex, 
in  part  direct. 

Herzkammer.     Arch.  f.  Anatomie  u.  Physioldgie,  Abtheilung  f.  Physiologie, 
1887,  p.  452. 

1  Munzel,  E.  Pulsfolge  und  Blutdruck  nach  der  Durchschneidung  der  Nervi 
Vagi.    Arch.  f.  Anatomie  u.  Physiologie.     Physiol.  Abtheilung,  1887,  p.  131. 

2  Frank,  O.  Einfluss  der  Haiifigkeit  des  Herzschlages  auf  den  Blutdruck. 
Zeitschr.  f.  Biol.,  1901,  vol.  xxiii,  p.  1. 

^  Marey,  I.  Recherches  sur  le  pouls  an  moyen  d'un  nouvel  appareil  enre- 
gistreur  le  Sphygmograph.  Comptes  Rendus  des  Seance  et  Menioires  de  la 
Societe  de  Biologic,  1859,  p.  301  and  following.  Compare  also,  Loi  qui  preside  a 
la  frequence  des  battements  du  coeur.  Comptes  Rendus  Hebdomadaires  des 
Seances  de  I'Academie  des  Sciences,  1861,  vol.  Iviii,  pp.  95-98.  La  circulation 
du  sang  a  I'etat  physiologique  et  dans  les  maladies,  Paris,  1881,  pp.  334-340. 

•*  Tigerstedt,  Lehrbuch,  pp.  295-398. 


14  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

The  reflex  reaches  the  vagus  centre  by  way  of  the  most 
important  centripetal  nerve  of  the  heart,  the  depressor  nerve. 
This  nerve,  which  exists  as  a  separate  anatomical  structure  in 
various  warm-blooded  animals,  and  whose  homologue  has  been 
traced  in  man,  has  its  endings  in  the  ventricular  wall  and  its 
central  connections  through  the  vagus.  If  it  be  divided,  no 
change  in  heart  action  or  blood-pressure  normally  follows ; '  and 
the  same  holds  true  if  its  peripheral  end  be  stimulated.  It  is 
therefore  wholly  centripetal,  and  possesses  no  tonus.  If,  on 
the  other  hand,  its  central  cut  end  be  stimulated,  a  marked  fall 
in  blood-pressure  and  slowing  of  the  heart  follow.  The  former, 
as  we  shall  see  subsequently,  is  due  to  an  inhibition  of  the  vaso- 
motor centre.  The  latter,  since  it  never  occurs  after  division 
of  the  vagi,  must  be  dependent  on  stimulation  of  the  centre  for 
these  nerves.  In  the  depressor  nerve,  then,  the 
heart  possesses  a  protective  mechanism  of  the 
first  importance,  by  means  of  which  it  is  able  to 
shield  itself  automatically  from  the  overwork 
entailed  by  continued  high  blood-pressure.  Under 
ordinary  life  conditions  the  nerve  is  probably  put  in  action 
through  the  stimulation  of  its  endings  by  the  abnormal  tension 
of  the  ventricular  wall,  which  high  pressure  causes. 

The  direct  action  of  high  arterial  pressure  upon  the  vagus 
centre  was  demonstrated  by  Franck,^  who  isolated  the  brain 
from  the  rest  of  the  body  of  a  dog,  leaving  only  the  vagi  intact. 
Through  the  severed  carotids  he  kept  up  an  artificial  circulation^ 
and  whenever  he  increased  the  pressure  within  them  the  heart- 
beat became  slower.  The  same  effect  has  been  produced  by 
increasing  intracranial  pressure  through  a  trephine  opening 
(Leyden),^  and  the  fact  has  important  clinical  bearinga. 

The  effect  of  the  blood-pressure  upon  the  volume  output  of 
the  ventricle  is  a  complicated  one  and  observations  on  it  do  not 
show  uniform  results.     The  output  depends  largely  upon  the 

'  Ijiulwig  u.  Cyon.  Ber.  d.  sachsischen  Gesellsch.  d.  Wiss.,  math.  phys.  CI., 
1860,  p.  .319.     Quoted  by  Tigerstedt,  Lehrbuch,  p.  280. 

'  Franck.  Traveaux  du  laboratoire  dc  Marcy,  1877,  vol.  iii,  pp.  27G  and 
following. 

"  Leyden,  E.  Beitrage  und  Untersuchiingon  zur  I'hysiologio  iind  Pathologic 
des  (iehirns.  Arch.  f.  pathol.  Anat.  u.  Physiol,  u.  f.  klin.  ]\Ied.,  1866,  vol. 
XXXV ii,  p.  1550. 


FACTORS   DETERMINING   BLOOD-PRESSURE    15 

amount  of  blood  brought  to  the  heart  by  the  great  veins/  and 
in  this  way  abdominal  massage  produces  a  rise  in  blood-pres- 
sure ;  but  with  a  high  peripheral  resistance  the  heart  will  not 
empty  itself  of  the  increased  volume  and  the  rise  will  be 
absent.^  Plethysmographic  studies  by  Roy  and  Adami,^  and 
others,  show  an  increasing  quantity  of  blood  remaining  in  the 
ventricle  after  systole,  at  high  pressure,  even  though  the  volume 
output  maybe  increased.  There  is,  therefore,  a  limit 
to  the  reserve  force  of  the  heart,  so  that,  if  the 
peripheral  resistance  be  too  much  increased,  the 
volume  output  of  the  ventricle  will  diminish. 
This,  as  well  as  the  reflex  depressor  mechanism,  set  an  upper 
limit  to  the  blood-pressure,  beyond  which  no  increase  in  periph- 
eral resistance  or  total  blood- volume  can  augment  it. 

Marked  lowering  of  blood-pressiire,  especially  of  the  degree 
obtained  after  section  of  the  splanchnic  nerves  or  spinal  cord,  by 
diminishing  the  amount  of  blood  returned  to  the  heart,  has  a 
considerable  indirect  effect  on  the  cardiac  energy,  O.  Frank* 
showed  plainly  in  the  isolated  frog's  heart,  that  when  the  fill- 
ing of  the  ventricle  is  much  decreased  the  energy  of  contrac- 
tion is  conspicuously  less.  This  in  turn  will  produce  a  still 
further  fall  in  pressure,  and  hasten  the  death,  which,  we  shall 
see  later,  follows  complete  vaso-motor  paralysis. 

In  this  connection,  the  effect  on  blood-pressure  of  increasing 
the  intra-abdominal  pressure  may  be  mentioned.  It  has  been 
investigated  most  recently  by  Quirin,^  who,  like  previous 
observers,  finds  that,  up  to  a  certain  point,  increasing  abdomi- 
nal pressure  raises  the  arterial  pressure.  Beyond  this  point  it 
causes  a  fall  in  blood-pressure,  which  will  finally  lead  to  death 

1  Howell  and  Donaldson.  Philosophical  Transactions,  1884,  pp.  152-154. 
Quoted  by  Tigerstedt,  Lehrbuch,  p.  297. 

^  Tigerstedt,  Robert.  Studien  iiber  die  Blutverteilung  im  Korper.  Skandi- 
navisches  Arch.  f.  Physiol.,  1891-92,  vol.  iii,  pp.  207-219. 

^  Roy,  Professor,  and  Adami,  I.  G.  Remarks  on  Failure  of  the  Heart  from 
Overstrain.     Brit.  Med.  Jour.,  1888,  vol.  ii,  pp.  321  and  following. 

*  Frank,  0.  Zur  Dynamik  des  Herzmuskels.  Zeitschr.  f.  Biologie,  1895, 
vol.  xxxii,  p.  370,  and  Isoraetrie  nnd  Isotonic  des  Herzmuskels.  Zeitsclir.  f. 
Biologie,  1901,  vol.  xli,  p.  14. 

^  Quirin,  Alexander.  Ueber  das  Verhalten  des  normalen  und  pathologisch 
gesteigerten  intraabdominalen  Druckes  und  seine  Riickwirkung  auf  die  arteri- 
elle  Blutcirculation.     Deutsch.  Arch.  f.  klin.  Med.,  1901,  vol.  Ixxi,  p.  79. 


16  BLOOD-PRESSURE   IN  THE   NORMAL  ANIMAL 

of  the  animal,  if  compression  of  the  abdomen  be  continued. 
The  explanation  of  the  primary  rise  is  unquestionably  the 
emptying  of  the  contents  of  the  abdominal  veins  into  the  right 
heart,  followed  by  increasing  resistance  due  to  compression  of 
the  abdominal  arteries.  When  this  becomes  too  great,  the 
heart,  which  at  the  same  time  receives  a  diminished  amount  of 
blood  from  the  veins,  exhausts  its  reserve  force,  and  the  blood- 
pressure  rapidly  falls  until  the  heart  ceases  to  beat. 

B.  The  Peripheral  Resistance. — In  the  simple  experiment 
with  a  distensible  tube,  it  is  plain  that  narrowing  the  outlet, 
other  conditions  remaining  unchanged,  causes  a  rise  in  pres- 
sure within  the  tube.  The  same  holds  equally  for  the  arterial 
system.  Increased  resistance  and  higher  pres- 
sure, diminished  resistance  and  lower  pressure, 
are  invariable,  unless  some  counterbalancing 
change  in  the  force  of  the  heart  occurs. 

Since  normally  there  exists  a  considerable  pressure  within 
the  arteries,  there  must  be  a  well-marked  resistance  as  its 
cause.  A  small  part  of  this  is  due  to  friction,  dependent  on 
the  viscosity  of  the  blood  and  the  continual  branching  of  the 
arterial  tree  into  smaller  and  smaller  subdivisions.  The  really 
effectual  cause,  however,  is  the  so-called  tonus  of  the  blood- 
vessels, the  state  of  partial  contraction  which  the  unstriped 
muscle  of  their  walls  maintains  continuously  during  health. 
From  the  standpoint  of  the  blood- pressure  and  its  variations, 
the  vaso-motor  mechanisms  are  by  far  the  most  important 
facts  in  circulatory  physiology,  and  should  be  carefully  studied 
by  all  who  attempt  the  interpretation  and  clinical  use  of  blood- 
pressure  determinations.  Our  knowledge  we  owe  to  many  in- 
vestigators, beginning  with  Henle,  Claude  Bernard,  Brown- 
Sequard  and  Schiff.  Only  the  most  important  facts  for  the 
clinician,  among  the  vast  number  which  have  been  accumu- 
lated in  this  field,  can  be  touched  on  here. 

All  blood-vessels  which  contain  any  muscle 
fibre  possess  tonus;  that  is,  not  only  the  ar- 
teries, but  also  the  veins.  This  has  been  proved  by 
Mall '  for  the  portal  vein.     He  compressed  the  aorta  high  up 

•  Mall,  F.  Der  Einfluss  ties  Systems  tier  Venae  portae  auf  die  Verteilung 
des  Blutes.  Arch.  f.  Anat.  u.  Physiol.  Physiol.  Abth.,  1892,  pp.  418  and  fol- 
lowing. 


FACTORS   DETERMINING   BLOOD-PRESSURE    17 

so  as  to  cut  off  the  abdominal  circulation,  and  then,  on  stimu- 
lation of  a  splanchnic  nerve,  observed  visible  contraction  of 
the  portal  vein,  which  emptied  its  contents  into  the  liver,  v. 
Bezold  and  Gscheidlen  ^  noted  the  same  for  the  general  circu- 
lation, by  stimulating  the  spinal  cord  after  the  heart  had 
ceased  to  beat. 

Under  normal  conditions  the  tone  of  the  ves- 
sels depends  on  the  balance  between  the  oppos- 
ing action  of  two  sets  of  nerves,  vaso-constric- 
tor  and  vaso-dilator.  The  existence  and  course  of  these 
nerves  has  been  demonstrated  for  practically  every  organ  and 
portion  of  the  body,  the  brain  excepted.^  The  constrictor 
nerves  are  the  more  important  for  the  general,  if  not  for  the 
local,  circulation.  Their  tonus  is  derived  in  the  first  instance 
from  the  vaso-constrictor  centre,  situated  in  the  upper  part  of 
the  medulla  oblongata.  Section  of  the  medulla  below  the 
centre  is  followed  by  dilatation  of  all  the  arteries  of  the  body 
and  great  fall  in  blood-pressure.  If  the  peripheral  cut  end  be 
stimulated,  a  rise  in  pressure  occurs,  which  may  reach  the  ex- 
treme height  of  seven  times  the  previously  existing  figure. 
That  this  is  due  to  a  general  constriction  of  the  peripheral 
arteries  was  made  certain  by  Ludwig  and  Thiry,^  and  by 
Goltz,  *  who  obtained  the  same  rise  after  section  of  all  the  car- 
diac nerves;  V.  Bezold,^  who  first  performed  the  experiment, 
having  considered  it  due  to  accompanying  increased  heart- 
action. 

This  bulbar  centre  is  not  the  only  one,  however,  for,  after 
section  of  the  cervical  cord,  the  arteries  may  in  time  recover 
their  tone.     Other  centres  are  therefore  present  in  the  lower 

1  V.  Bezold,  A.,  and  Gscheidlen,  Rich.  Von  der  Locomotion  des  Blutes 
durch  die  glatten  Muskeln  der  Gefasse.  Untersuchungen  ans  dem  physiol. 
Lab.  in  Wiirzburg,  1867,  pp.  355  and  following. 

*  Hill,  Leonard.     The  Cerebral  Circulation.     London,  1896. 

3  Ludwig  und  Thiry.  Sitzungsber.  d.  kais.  Akad.  d.  Wissensch.,  math, 
naturw.  CI.,  1864,  vol.  xlix,  Abth.  2,  pp.  421-454.  Quoted  by  Tigerstedt,  Lehr- 
buch,  p.  542. 

*  Goltz,  Pr.  Ueber  den  Tonus  der  Gefasse  und  seine  Bedeutung  fiir  die 
Blutbewegung.  Arch.  f.  pathol.  Anatomie  u.  Physiologie  und  f.  klin.  Med., 
1864,  vol.  xxix,  pp.  394-432. 

*  V.  Bezold,  Albert.  Untersuchungen  iiber  die  Innervation  des  Herzens, 
1863,  2te  Abt.,  pp.  219  and  following. 

3 


18  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

neurons.  If,  instead  of  simply  cutting  the  cord,  it  be  de- 
stroyed throughout  its  whole  length,  the  vessels  never  recover 
their  tone,  the  blood  all  collects  in  the  veins,  the  heart-beat 
becomes  progressively  weaker,  and  death  ensues.^  (Compare 
page  15,  this  chapter.)  Such  an  experiment  proves  conclu- 
sively that  the  vaso-motor  tone  is  an  absolute  ne- 
cessity for  the  maintenance  of  the  circulation, 
that  of  the  veins  equally  with  the  arteries;  only 
by  the  existence  of  it  is  an  adaptation  of  the 
total  vascular  stream-bed  to  the  blood-volume 
possible.  Its  absence  is  followed  by  stagnation 
of  the  blood  in  the  veins  and  eventual  failure  of 
the  heart,  because  no  blood  is  brought  to  it.  It 
also  demonstrates  the  existence,  below  the  bulbar,  of  spinal 
vaso-motor  centres,  which  are  of  the  first  importance.  In  the 
study  of  the  local,  not  the  general,  circulation,  lower  centres 
have  been  found,  which  are  very  probably  in  the  sympathetic 
ganglia.  Their  existence  is  evidenced  by  the  return  of  tone  in 
the  vessels  of  the  dog's  legs  a  number  of  days  after  destruction 
of  the  lumbar  cord,  which  contains  the  spinal  centres  for  the 
lower  extremity ;  ®  also  by  the  gradual  recovery  of  tone  in  iso- 
lated arteries  all  of  whose  vaso-motor  nerves  have  been  sev- 
ered. *  These  peripheral  centres  are  important  as  explaining 
the  probable  mechanism  of  the  action  of  the  vaso-dilator 
nerves,  and  for  the  vascular  reflexes;  but,  as  already  said, 
they  cannot  suffice  for  the  recovery  of  general  vaso-motor  tone 
throughout  the  body  after  destruction  of  the  cord. 

The  vaso-dilator  nerve-fibres  possess  no 
tonus,  and  section  of  them  causes  no  narrowing  of  the  cor- 
responding arteries.  They  have  not,  therefore,  the  vital  sig- 
nificance of  the  vaso-constrictors.  For  the  adjustment  of  the 
local  circulation  to  the  demands  made  upon  it,  especially  in 
relation  to  the  blood-supply  of  secreting  glands,  they  are  of 

'  Goltz,  Fr.  Ueber  den  Tonus  der  GefJisse  und  seine  Bedeutung  fur  die 
Blutbewegung.  Arch.  f.  pathol.  Anatomie  u.  Physiologic  und  f.  klin.  Med., 
1864,  vol.  xxix,  p.  422.  Ueber  die  Fiinctionen  des  Lendenmarks  des  Ilundes, 
Arch.  f.  d,  gesam.  Physiol,  d.  Menschen  u.  d.  Thiere,  1874,  vol.  viii,  pp.  485 
and  following. 

'  Goltz,  Fr.,  und  Ewald,  0.  R.  Der  Ilund  mit  vcrkiirztem  RUckenmark. 
Arch.  f.  d.  gesam.  Physiol.,  189G,  vol.  Ixiv,  p.  397. 

'  Tigerstedt,  Lehrbiich,  p.  51.3. 


FACTORS   DETERMINING   BLOOD-PRESSURE    19 

great  use.  In  this  way  their  activity  affects  the  general  blood- 
pressure.  Their  first  absolute  demonstration  was  in  the  chorda 
tympani  nerve  by  Claude  Bernard/  and  the  extent  of  their  in- 
fluence may  be  judged  from  the  fact  that,  in  his  experiment, 
their  stimulation  increased  the  blood  stream  in  the  vein  lead- 
ing from  the  submaxillary  gland  from  5  c.c.  in  sixty-five 
seconds  to  5  c.c.  in  fifteen  seconds,  and  the  flow  pulsated  as 
from  an  open  artery. 

Anatomically,  constrictor  and  dilator  fibres  are  frequently 
found  in  the  same  nerve,  as,  for  instance,  the  splanchnic. 
When  thus  associated  they  are  distinguished  by  their  different 
reaction  to  electrical  stimulation,  the  dilators  being  affected  by 
currents  of  weaker  strength,  and  shocks  in  slower  rhythm ;  they 
also  respond  less  quickly,  but  continue  longer  in  action.  The 
vaso-dilator  centres  are  not  thoroughly  known,  but  exist  at 
least  in  the  spinal  cord. 

The  vaso-motor  tone  in  particular  vascular 
areas  varies  constantly  in  response  to  local 
needs.  This  is  a  physiological  necessity,  since  increased 
function  of  a  part  must  always  be  accompanied  by  increased 
blood-flow.  It  can  be  observed  most  easily  in  muscles,  and  in 
glands,  secretion  being  attended  by  a  very  great  increase  in 
the  amount  of  blood  passing  through  their  vessels.  This,  of 
course,  is  provided  by  a  dilatation  of  the  arteries  throughout 
the  gland.  Such  a  general  dilatation  of  the  small  arteries  in 
any  vascular  area  causes  a  fall  in  lateral  pressure  in  the  main 
artery  supplying  it.  If  the  area  be  of  sufficient  extent,  and  is 
not  compensated  for  by  vaso-constriction  in  other  vascular 
districts,  a  fall  in  mean  aortic  blood-pressure  follows.  On  the 
other  hand,  the  total  end  pressure  in  the  smaller 
arteries  is  increased  by  their  dilatation,  since 
less  energy  is  lost  in  overcoming  friction  central  to  them, 
and,  what  is  most  important,  when  certain  clinical  methods 
are  considered,  the  maximum  systolic  pressure 
rises  markedly.  That  this  must  be  so  is  obvious  from 
Bernard's  experiment,  in  which  the  pulse,  ordinarily  imper- 
ceptible in  the  smallest  arteries,  became  evident  even  in  the 

^  Bernard,  Claude,  Le§ons  sur  les  liquides  de  I'organisme.  Paris,  1859, 
vol.  i,  pp.  310-311 ;  vol.  ii,  p.  275.  Quoted  by  Tigerstedt,  Lehrbuch,  pp.  494 
and  502. 


FACTORS   DETERMINING   BLOOD-PRESSURE    21 


vein.  The  mechanism  by  which  this  variation  in  vascular 
tonus  is  brought  about  is  a  reflex  one,  either  constrictor  or 
dilator  action  being  stimulated  or  inhibited,  in  response  to  a 
stimulus  reaching  the  local,  spinal,  or  bulbar  centres  along  a 
centripetal  nerve. 

Vaso-motor  tone,  both  local  and  general,  is 
markedly  affected  by  reflexes  of  remote  origin. 
These  vascular  reflexes  are 
of  great  significance  for  the 
general  blood-pressure,  a  s 
well  as  for  the  distribvition  of 
the  blood,  and  have  been  ex- 
tensively studied.  They  may 
be  provoked  by  the  stimula- 
tion of  any  afferent  nerve. 
The  only  such  nerve  in  the 
entire  body,  stimulation  of 
which  invariably  lowers 
blood -pressure,  is  the  depres- 
sor nerve.  The  fall,  in  this 
case,  is  due  chiefly  to  a  dilata- 
tion of  the  splanchnic  ves- 
sels ;  but  not  wholly,  for  some 
lowering  occurs  after  section 
of  the  splanchnic  nerves. 

With  this  single  excep- 
tion, stimulation  of  any  cen- 
tripetal nerve  as  a  rule  raises 
blood-pressure.  This  is  easily 
shown  on  stimulation  of  the 
central  cut  end  of  the  sciatic, 
anterior  crural,  or  other  large 
nerve  trunk,  and  similar  re- 
flexes occur  on  irritation  of 
parts  of  the  cerebral  cortex. 

The  sensory  nerves,  however,  contain  some  depressor  fibres,  for 
HoweU  ^  has  shown  that,  if  the  sciatic  is  cooled  to  0°  C.  central 

1  Howell,  Budgett,  and  Leonard.  The  Effect  of  Stimulation  and  of  Changes 
in  Temperature  upon  the  Irritability  and  Conductivity  of  Nerve  Fibres.  Jour, 
of  Physiol.,  1894,  vol.  xvi,  p.  298. 


Ftg.  5. — Rise  in  blood-pkesscke  pkoduckd 
by  stimulation  of  the  anteriok  crural 
NERVE  (pressor  effect). 

Trace  from  clog's  carotid.   Tetanizing  current. 


22  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

to  the  point  of  stimulation,  a  fall  in  pressure  replaces  the  ordi- 
nary rise.  Similarly,  Hunt  ^  found,  that,  in  the  early  period  of 
regeneration  of  the  cut  sciatic,  only  reflex  vaso-dilatation  fol- 
lows stimulation,  the  reflex  constriction  being  obtained  later, 
when  the  nerve  has  been  more  completely  repaired.  Mechan- 
ical stimulation  of  the  skeletal  muscles,  and  of  the  mucous 
membrane  of  rectum  and  vagina,  commonly  results  in  a  fall  in 
pressure.'  According  to  Porter,^  this  happens  more  readily 
when  the  animal  is  under  ether,  chloroform,  or  chloral,  than 
under  curare.  This  has  a  clinical  bearing  in  relation  to  sur- 
gical shock,  a  condition  in  which  depressor  reflexes  take  the 
place  of  the  normal  pressor  ones. 

In  reflex  rises  of  pressure,  the  largest  factor  is  vaso-constric- 
tion  in  the  splanchnic  area,  though  other  vessels  participate. 
With  the  exception  of  the  brain  vessels,  in  which  vaso-motor 
changes  have  not  been  proven,  the  arteries  of  the  muscles  show 
the  smallest  reflex  variation. 

Of  all  the  parts  of  the  vascular  system,  the 
abdominal  vessels,  innervated  by  the  splanch- 
nic nerves,  have  by  far  the  greatest  effect  on 
general  b  1  o  o  d  -  p  r  e  s  s  u  r  e .  This  is  one  of  the  most  essen- 
tial facts  to  bear  in  mind  clinically.  The  extent  to  which  sec- 
tion of  the  splanchnic  nerves  lowers  the  mean  aortic  pressure 
varies  somewhat  in  different  animals;  in  rabbits  it  almost 
equals  section  of  the  cervical  spinal  cord,  while  in  the  dog  and 
cat  it  is  less  extreme.  In  all  cases,  however,  and  undoubtedly 
in  man  as  well,  the  chief  control  of  general  blood-pressure  is 
lodged  here.  One  reason  for  this  may  be  found  in  the  size  of 
this  vascular  area,  which  includes  the  portal  vein  and  its 
branches,  and  is  large  enough  to  contain  almost  the  whole 
blood- volume  of  the  body.  A  second  reason  is  the  fact  that  of 
all  the  vaso-motor  nerves,  the  splanchnics  are  the  most  easily 
affected  by  reflexes  from  any  sensory  nerve.* 

The  proof  of  their  importance  was  furnished  first  by  Ludwig 


'  Hunt.  The  Pall  of  Blood-Pressure  Resulting  from  the  Stimulation  of 
Afiferent  Nerves.    Jour,  of  Physiol.,  1895,  vol.  xviii,  p.  381. 

»  Tigerstedt,  Lehrbuch,  pp.  528,  529. 

'  Porter,  W.  T.  Aincr.  Text-Book  of  Physiol.,  second  edition,  1900,  vol.  i, 
p.  203. 

*  Tigerstedt,  Lehrbuch,  p.  520. 


FACTORS   DETERMINING   BLOOD-PRESSURE    23 

and  Cyon/  and  by  v.  Bezold  and  Bever.^  The  former  found 
that,  after  section  of  one  nerve,  the  aortic  pressure  sank  about 
30  to  50  mm. ;  if  the  second  were  then  cut,  a  further  fall  of  8 
to  10  mm.  was  obtained.  The  latter  observed  practically  the 
same  lowering  of  pressure  after  section  of  both  splanchnics  in 
the  thorax,  as  after  division  of  the  cord  high  up.  When  one 
considers  that  section  of  the  cervical  sympathetic,  which  in- 
nervates all  the  vessels  of  the  head,  exerts  no  material  influence 
on  aortic  pressure,  these  facts  become  sufficiently  striking. 
That  the  greater  splanchnic  nerves  are  not  the  sole  vaso-motor 
supply  for  the  abdominal  organs,  has  been  proved  by  Asp,^ 
who  found,  after  their  division,  a  return  of  blood-pressure  to 
its  normal  level  in  eleven  or  twelve  days.  This  double  inner- 
vation holds  good  for  most  arteries  and  in  no  wise  detracts 
from  the  fundamental  importance  of  the  vessels  of  the  abdom- 
inal viscera,  as  the  main  source  of  the  normal  peripheral 
resistance. 

An  equally  striking  demonstration  that  the  intact  splanch- 
nic circulation  can  compensate  for  the  most  extreme  narrowing 
of  the  rest  of  the  arterial  tree  was  furnished  by  the  experiments 
of  V.  Bezold,^  and  of  Ludwig  and  Thiry,^  which  have  been  fre- 
quently corroborated  since.  The  former  showed  that,  in  an 
animal  with  severed  cervical  cord,  ligature  of  the  abdominal 
aorta  itself,  just  below  the  renal  arteries,  had  practically  no 
effect  on  the  carotid  pressure,  or  on  the  frequency  and  force  of 
the  heart.  The  latter,  under  similar  conditions,  found  a  strik- 
ing rise  on  ligature  of  the  aorta  above  the  diaphragm,  that  is, 
above  the  origin  of  the  splanchnic  vessels.  These  observations 
are  of  fundamental  importance  in  the  interpretation  of  the 
effects  of  arterio-sclerosis  on  the  heart. 

'  Ludwig  und  Cyon.  Bericht  der  sachsischen  Gesellsch.  der  Wissenschaften, 
math.  phys.  CI.,  1866,  p.  315.     Quoted  by  Tigerstedt,  Lehrbuch,  p.  488. 

°  Bever,  Carl,  und  v.  Bezold,  A.  Von  den  Wirkungen  der  Nervi  splanch- 
nichi  auf  den  Blutdruck  im  Aortensystenie.  Untersuch.  aus  dem  physiolog. 
Lab.  in  Wiirzburg,  vol.  i,  1867,  pp.  314-325. 

'  Asp.  Bericht  der  saeh.  Gesellsch.  der  Wissensch.,  math.  phys.  CI.,  1867, 
pp.  141,  142.     Quoted  by  Tigerstedt,  Lehrbuch,  p.  491. 

^  V.  Bezold,  A.  Untersuch ungen  iiber  die  Innervation  des  Herzens,  Leipzig, 
1863,  pp.  223-229. 

^  Ludwig  und  Thiry.  Sitzungsber.  d.  kais.  Akad.  d.  Wiss.,  math,  naturw. 
CI.,  1864,  vol.  xlix,  2,  p.  442. 


24  BLOOD-PRESSURE   IN   THE   NORMAL  ANIMAL 

Finally,  it  must  be  remembered  tbat,  in  reflex  raising 
or  lowering  of  blood -pressure,  all  the  arteries 
of  the  body  are  not  contracted  or  dilated  at  the 
same  time.  In  general  there  seems  to  be  an  antagonism 
between  the  vessels  of  the  internal  organs  and  those  of  the  skin 
and  muscles,  so  that  the  one  set  will  be  more  or  less  widened 
when  the  other  becomes  narrowed.  This,  however,  is  by  no 
means  invariable,  and,  under  certain  circumstances,  both  may 
be  constricted  together.^ 

C.  The  Elasticity  of  the  Arterial  Wall.— Were  it  not  for  the 
distensibility  of  the  arteries,  the  work  of  the  heart  would  be 
many  times  greater  than  it  is.  Each  systole  would  then  hav6 
to  propel  the  total  blood-column,  and,  during  the  period  of 
active  ventricular  contraction,  displace  into  the  capillaries  an 
amount  equal  to  that  injected  into  the  aorta.  The  systolic 
blood-pressure  would  then  be  extreme,  the  diastolic  practically 
zero,  and  the  flow  intermittent.  The  elastic  arterial  wall  is  a 
mechanical  device  of  great  importance.  In  it  during  systole  a 
large  part  of  the  energy  of  the  ventricles  is  made  potential,  to 
be  utilized  in  moving  the  blood  during  diastole,  thus  converting 
an  intermittent  into  a  continuous  propelling  force,  and  distrib- 
uting the  heart's  work  over  more  than  twice  the  time  of  its 
actual  muscular  contraction. 

The  elasticity  of  the  arteries  is  very  perfect;  that  is,  they 
may  be  much  distended  by  pressure  and  subsequently  resume 
their  original  size.  In  the  terminology  of  physics  they  possess 
wide  limits  of  elasticity,  as  does  india-rubber.  It  is  this  prop- 
erty of  elastic  distensibility  which  is  important.  They  also 
possess  coefficients  of  elasticity,  which  are  more  than  ample  to 
enable  them  to  endure,  without  breach  of  continuity,  any  pres- 
sure they  may  ever  be  subjected  to  during  life.  Grehant  and 
Quinf^uard  ^  found  that  the  carotid  of  a  dog  could  stand  a  pres- 
sure twenty  times  greater  than  the  normal  blood-pressure  with- 
out tearing.  For  the  human  carotid  the  lowest  pressure  at 
which  rupture  occurred  was  1.29  m.  of  mercury,  at  least  eight 
times  ordinary  carotid  pressure.     It  is  therefore  safe  to  assume 

1  Tigerstedt,  Lehrbuch,  p.  520. 

"^  Grehant,  N.,  et  Quinquard,  11.  Mosure  dc  la  pression  neeessaire  pour 
determiner  la  rupture  des  vaisseaux  sanguiiis.  Jour.  d.  I'Anat.  et  de  la  Physiol, 
normal  et  pathol.  dc  riiommc  et  des  aiiinuiux,  1885,  vol.  xxi,  pp.  287,  297. 


FACTORS   DETERMINING   BLOOD-PRESSURE    25 

that  a  healthy  artery  cannot  be  torn  by  any  increase  in  blood- 
pressure  which  is  possible  during  life. 

Even  under  physiological  conditions,  however,  the  limits  of 
elasticity  of  the  arteries  are  not  constant,  but  vary  with  the 
internal  tension  to  which  they  are  subjected.  The  exact  man- 
ner in  which  the  change  occurs  is  somewhat  in  dispute,  Roy's,  ^ 
and  Zwaardemaker's  ^  experiments  having  shown  the  greatest 
elasticity  at  about  the  lower  limit  of  normal  blood-pressure  for 
the  animal,  the  elasticity  decreasing  at  higher  and  lower  pres- 
sures; Marey,^  and  Thoma  and  Kaefer,*  on  the  other  hand, 
finding  the  maximum  in  the  unstretched  artery,  and  a  progres- 
sive loss  of  elasticity  the  higher  the  absolute  pressure  was 
raised.  At  least  one  fact  is  secure;  at  a  high  arterial 
pressure  the  distensibility  of  the  arteries  is 
distinctly  diminished,  and  any  increase  in  the 
systolic  pulse-volume  must  raise  the  blood- 
pressure  far  more  than  a  corresponding  increase 
at  lower  pressures.  Not  only  is  this  true  as  regards 
mean  blood-pressure,  but  still  more  so  when  we  consider  sys- 
tolic pressure,  as  will  be  seen  in  the  study  of  certain  morbid 
states.  That,  under  these  circumstances  in  the  normal  animal, 
the  ventricle  does  not  empty  itself  completely  is  probable ;  but 
in  certain  pathological  conditions,  in  which  high  tension  and  a 
hypertrophied  ventricle  coincide,  this  diminishing  arterial  dis- 
tensibility, and  consequent  increase  in  the  systolic  elevation  of 
pressure,  should  be  borne  in  mind. 

D.  The  Volume  of  Circulating  Blood.— The  most  conspicuous 
fact  about  the  total  blood-volume  is  its  smallness,  when  compared 
to  the  full  cubic  capacity  of  the  arteries,  capillaries,  and  veins 
combined.  This  disproportion  is  compensated  for,  in  the  normal 
animal,  by  the  continuous  contraction  of  the  smaller  arteries, 

1  Roy,  Charles  S.  The  Elastic  Properties  of  the  Arterial  Wall.  Jour,  of 
Physiol.,  1881,  vol.  iii,  p.  141. 

*  Zwaardemaker,  Dr.  Over  de  Nitzetting  der  Slagaderen  voor  den  Bloeds- 
di-uk.  Nederlandsch  Tijdschrift  voor  Geneeskunde,  Tweede  Reeks,  1888,  vol. 
xxiv,  i,  pp.  61-78. 

^  Marey.  Travaux  du  laboratoire  de  M.  Marey,  1880,  vol.  iv,  pp.  178  and 
following. 

*  Thoma,  R.,  und  Kaefer,  N.  Ueber  die  Elasticitat  gesunder  und  kranker 
Arterien.  Arch.  f.  pathol.  Anat.  u.  Physiol,  u.  f.  klin.  Med.,  1889,  vol.  cxvi, 
pp.  9  and  following. 


26  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

which  we  have  studied  as  the  vaso-motor  tone.  Hence,  as  we 
have  seen,  when  this  tonus  is  wholly  abolished  by  destruction 
of  the  spinal  cord,  the  blood- volume  is  insufficient  to  fill  all  the 
vessels,  and  is  rapidly  forced  out  of  the  arteries  into  the  veins 
until  death  ensues,  the  animal  practically  bleeding  to  death 
into  its  own  veins. 

As  a  factor  in  the  control  of  the  blood-pressure  it  is  of  less 
importance  than  the  foregoing,  chiefly  because  its  variations 
are  so  easily  compensated  for.  That  death  from  haemorrhage 
is  attended  by  a  fall  in  the  blood-pressure  is  obvious.  Under 
normal  conditions,  however,  the  abstraction  of  considerable 
amounts  of  blood  causes  a  temporary  fall  in  pressure,  soon  fol- 
lowed by  a  rise  to  near  the  former  point.  Tappeiner^  found 
that  one-fifth  of  the  total  blood-volume  could  be  lost,  and, 
within  a  short  time,  the  pressure  again  reach  a  height  sufficient 
to  support  life.  The  chief  mechanism  by  which  this  is  brought 
about  is,  of  course,  the  increase  of  peripheral  resistance  through 
vaso-constriction.  It  is  well  known,  though,  that  after  severe 
hsemorrhage  the  kidneys  secrete  little  urine,  and  Langley^ 
has  shown  the  same  effect  upon  the  salivary  glands.  It  is  also 
possible  that  the  tissues  return  more  fluid,  and  the  liver  more, 
of  its  blood,  to  the  general  circulation.  The  heart's  rate  in- 
creases greatly  with  loss  of  blood,  and  it  may  be  sui3posed  to 
empty  itself  as  completely  as  possible,  so  that  really  great 
losses  (up  to  two-fifths  of  the  total  blood- volume)  may  affect 
mean  blood-pressure  surprisingly  little. 

On  the  other  hand,  Worm-Miiller^  has  shown  that  an 
amount  of  fluid  greater  than  the  total  blood-volume  of  the 
body  can  be  transfused  into  the  vessels,  without  increasing 
the  blood-pressure  above  a  point  which  it  frequently  reaches 
under  ordinary  conditions.  Pawlow,*  in  the  same  way,  was 
able  to  feed  a  dog  enormous  quantities  of  bouillon  without  any 
rise  in  pressure.     In  such  experiments,  part  of  the  excess  vol- 

'  Tappeiner.  Bericht  der  saehs.  Gesellsch.  der  Wissensch.,  math.  phys. 
Classe,  1872,  pp.  199  and  following.    Quoted  by  Tigerstedt,  Lehrbuch,  p.  345. 

'  Langley.  Philosophical  Transactions,  1889,  vol.  clxxx  B,  p.  128.  Quoted 
by  Tigerstedt,  Lehrbuch,  p.  350. 

'  Worm-Miiller.  Bericht  der  siieh.  Gesellsch.  der  Wissensch.,  math.  phys. 
Classe,  1873,  pp.  573-664.    Quoted  by  Tigerstedt,  Lehrbuch,  p.  345. 

*  Pawlow,  Joh.  Zur  Lehre  iiber  die  Innervation  der  Blutbahn.  Arch.  f.  d. 
gesara.  Physiologic  d.  Menschen  u.  d.  Thicre,  1879,  vol.  xx,  pp.  23,  24. 


FACTORS   DETERMINING   BLOOD-PRESSURE    27 

ume  is  removed  from  the  circulation  by  the  secreting  organs, 
especially  the  kidney,  and  part  by  increased  transudation  into 
the  lymph  spaces  and  serous  cavities  ;  the  remainder  is  accom- 
modated by  the  vessels,  which  dilate,  either  through  a  direct 
vascular  reflex,  or  in  response  to  a  reflex  from  the  heart  by  the 


Fig.  6. — Fall  in  blood-pressure  produced  by  hemorrhage. 
Trace  from  rabbit's  carotid.    Slow  drum. 

depressor  nerve.  Under  certain  circumstances,  such  as  too 
rapid  infusion,  the  heart  may  empty  itself  less  completely 
(Johannson  and   Tigerstedt).^ 


^  Johannson,  J.  E.,  und  Tigerstedt,  Robert.  Ueber  die  gegenseitigen  Bezieh- 
ungen  des  Herzens  und  der  Gefasse,  Skandinaviscbes  Arch.  f.  Physiol.,  1889, 
vol.  i,  p.  397. 


28  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

Therefore,  within  certain  wide  limits,  the 
volume  of  circulating  blood  has,  in  the  normal 
animal,  only  a  subordinate  and  temporary  in- 
fluence on  mean  b  1  o o d - p r e s s u r e . 

It  is  evident  that  the  regulating  influences,  which  prevent 
excessive  increase  of  the  quantity  of  circulating  fluid,  will  not 
be  operative  when  that  quantity  has  been  abnormally  reduced. 
Thus  the  transfusion  of  blood,  or  the  infusion  of  normal  saline 
solution  into  the  veins,  after  profuse  hsBmorrhage,  brings  about 
a  prompt  rise  in  pressure.  Dawson  ^  has  shown  recently  that, 
if  the  solution  contain  0.25  per  cent,  sodium  bicarbonate  in 
addition  to  0.8  per  cent,  of  chloride,  both  the  systolic  and  dia- 
stolic pressures  will  be  higher  than  when  saline  alone  is  used. 

Since  our  clinical  methods  measure  systolic  or  diastolic,  but 
never  mean  pressure,  we  must  bear  in  mind  that  the  rise  in 
frequency  of  the  heart-beat,  which  is  one  of  the  greatest  com- 
pensating factors  after  haemorrhage,  must  be  attended  with 
diminished  systolic  pulse-volume.  This  necessarily  leads  to 
decrease  in  sj^stolic  and  diastolic  variation  in  pressure.  If  the 
mean  pressure  remains  unchanged,  systolic  pressure  must  fall 
and  diastolic  rise.  Experiment  XII,  in  the  work  of  Howell 
and  Brush,  given  on  page  34  of  this  chapter,  demonstrates 
this.  A  fall  in  mean  blood-pressure  during  haem- 
orrhage will  not  be  accurately  measured  by  the 
change  in  systolic  or  diastolic  pressure,  but 
will  be  magnified  by  the  foriner  and  minimized 
by   the   latter. 

3.   THE    MEAN    AORTIC    BLOOD-PRESSURE    IN 
DIFFERENT   ANIMALS 

No  fact  regarding  the  blood-pressure  is  better  established 
than  its  wide  range  of  variation  in  any  individual.  It  is  there- 
fore impossible  to  speak  of  a  normal  value  for  blood-pressure, 
but  only  of  certain  normal  upper  and  lower  limits.  In  con- 
secjuence  it  is  difficult  to  compare  the  values  found  in  different 
species,  except   as   rough   averages.     There  have  been   few 

'  Dawson,  Percy  M.  Effect  of  Intravenous  Infusion  of  Sodium  Bicarbonate 
after  Severe  Hjeinorrhage.  Am.  Journ.  of  Pliysiol.,  1904,  vol.  x,  Proceed,  of 
Am.  Physiol.  Soc,  p.  xxxvi. 


BLOOD-PRESSURE   IN   DIFFEREXT    AXDIALS    -29 

studies  on  this  question,  but  the  following  table,  copied  from 
Volkmann,^  illustrates  the  usual  figures  sufficiently  well. 


Blood-Pressure 
Animal  Species.  in  ram. 

of  Mercury. 

Horse 321 

Horse 214 

Sheep 206 

Calf 177 

Large  Dog 172 

Sheep....'. 169 

Dog 166 

Calf 165 

Dog 157 

Sheep 156 

Calf 153 

Horse  . .    150 


Blood-Pressure 
Animal  Species.  in  mm. 

of  Mercury. 

Cat 150 

Dog 143 

Goat  (female) 135 

Calf 133 

Large  Dog 123 

Horse,  old  and  thin 122 

Small  Goat  (male) 118 

Horse,  old 110 

Rabbit 108 

Dog,  young 104 

Sheep,  old 98 

Rabbit 90 


Yolkmann  concluded  from  these  that  the  size  of  the  animal 
does  not  determine  the  height  of  the  blood-pressure,  a  decision 
which  seems  only  partially  justified,  the  horse,  except  for  two 
old  animals,  showing  only  in  the  upper  half  of  the  hst,  and  the 
rabbit  among  the  lowest  figures.  If  we  consider  the  animals 
of  medium  size,  lea^Tng  out  the  horse  and  rabbit,  we  find  the 
figures  lying  between  98  mm.  and  "206  mm.,  readings  which  we 
shall  see  later  are  not  very  far  from  those  foimd  chnically  in 
man. 

As  regards  the  height  of  blood-pressure  in  different  individ- 
uals of  the  same  animal  species,  almost  as  great  variation 
seems  to  obtain.  Crile^  recorded  the  mean  carotid  pressure, 
under  full  ansesthesia,  in  100  dogs.  The  highest  was  IvO  mm., 
the  lowest  80  mm.,  the  average  135  nun.  There  was  no  rela- 
tion between  blood-pressure  and  body- weight. 

A.  Direct  Determinations  of  Hnman  Blood-Pressnre. — A  few 
observations  of  this  kind  have  been  made  in  the  course  of 
amputation,  the  pressures  found  in  the  femoral  and  brachial 
arteries  varving  between  100  mm.   and  160   mm.^'  *      These 


1  Die  Hamodvnamik.  1850,  pp.  177,  178. 

^  Crile,  Geo.  W.     Blood-Pressnre  in  Surgery.  Phila..  1903.  p.  359. 

^  Faivre,  I.  Etudes  Esperimentales  sur  les  Lesions  Organiques  du  Cceur. 
Gaz.  Med.  d.  Paris.  1856.  p.  727. 

*  Albert  E.  Einige  kyniographische  Messungen  am  Mensohen.  Med.  Jahr- 
biicher.     Wien,  1883,  p.  254. 


30  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

experiments  are  questionable  from  the  ethical  standpoint,  and 
the  results  are  useful  merely  as  showing  certain  possible  real 
values  for  human  arterial  pressure,  not  in  any  way  its  range. 

4.  THE  BLOOD-PRESSURE  IN  DIFFERENT  ARTERIES 

Since  the  various  clinical  methods  for  the  estimation  of 
blood-pressure  deal  with  arteries  as  different  in  calibre  and  in 
their  distance  from  the  heart,  as  the  brachial,  radial,  digital, 
temporal,  and  femoral,  it  is  important  that  we  should  know 
what  changes  in  pressure  occur,  as  the  blood  travels  from  the 
aorta  to  the  periphery.  Those  unfamiliar  with  the  experimental 
facts  might  suppose  that  there  is  a  continuous  and  more  or  less 
even  fall  in  pressure  from  the  largest  to  the  smallest  arteries. 
Poiseuille,^  however,  after  his  first  researches,  came  to  the  oppo- 
site opinion,  and  thought  that  the  mean  pressure  was  equal  in 
the  various  arteries  and  independent  of  their  distance  from  the 
heart.  This  is  not  strictly  true,  but  the  striking  fact  has  been 
established  by  all  subsequent  investigation,  that  the  lateral 
pressure  in  the  arteries,  of  not  too  small  diam- 
eter, diminishes  extremely  slowly  with  increas- 
ing distance  from  the  heart.  v.  Schulten,^  for 
instance,  found  that  the  maximum  pressure  in  the  ophthalmic 
artery  was  only  2  to  15  mm.  below  that  in  the  aorta.  Some 
experiments  of  Hiirthle's^  with  an  elastic  manometer,  which 
are  quoted  later  (see  page  33),  are  ecjually  demonstrative  of 
this  point. 

In  his  tables  the  constancy  of  diastolic  pressure  in  carotid, 
renal,  and  femoral  arteries  is  striking.  Recent  experiments  by 
Dawson,*  as  yet  unpublished,  showed,  for  the  dog,  the  greatest 
uniformity  in   minimum   pressure  throughout  all  the  larger 

'  Poiseuille,  J.  L.  D.  Recherches  sur  la  Force  du  Coeur  Aortique.  Thesis, 
Paris,  1828,  pp.  31  and  following.     Quoted  by  Tigerstedt,  Lehrbuch,  p.  351. 

^  V.  Schulten,  M.  W.  Untersuchungen  iiber  den  Ilirndruck,  mit  besonderer 
Riicksicht  auf  seine  Einwirkung  auf  die  Circulationsverhaltnisse  des  Auges. 
Arch.  f.  klin.  Chir.,  1885,  vol.  xxiii,  p.  463. 

'  Ilurthle,  Karl.  Ucber  den  Ursprungsort  der  sekundiiren  Wellcn  der  Puls- 
curve.  Arch.  f.  d.  gesara.  Pliysiologie  d.  Menschen  u.  d.  Thiere,  1890,  vol.  xlvii, 
pp.  32-34. 

*  Dawson,  Quoted  by  Erlangcr.  Am.  Journ.  of  Physiol.,  1904,  vol.  x.  Pro- 
ceed, of  Am.  Physiol.  Soc,  p.  xiv.    (Experiments  to  be  published  in  full  later.) 


BLOOD-PRESSURE   IN    DIFFERENT    ARTERIES    31 

arteries.  Tlie  work  of  Tsclinewsky/  also,  though  not  under- 
taken with  reference  to  this  particular  point,  showed  in  seven 
dogs  an  average  mean  pressure  in  the  femoral  of  77  mm. ;  in 
eight  dogs  of  similar  size  the  average  mean  pressure  in  the 
common  carotid  was  92.6  mm. 

Under  certain  conditions,  such  as  external  cold,  peripheral 
arteries  like  the  digital  may  become  much  contracted,  and  the 
pulse-wave  in  them  be  lost  nearer  the  heart  than  usual.  Under 
such  circumstances  the  lateral  pressure  in  them  will  fall  more 
rapidly  than  normal,  especially  the  systolic  pressure.  In 
general,  though,  it  may  be  accepted  that  no  marked  fall  occurs 
within  the  arterial  system  until  the  smallest  arteries  and  arte- 
rioles are  reached,  for  these  are  the  seat  of  most  of  the  periph- 
eral resistance.  Therefore,  in  the  larger  systemic 
arteries  used  for  the  clinical  estimation  of 
blood -pressure,  the  lateral  pressure,  especially 
the  diastolic,  closely  approximates  that  within 
the  aorta. 

In  the  lesser  circulation,  as  is  well  known,  much  lower 
pressures  obtain,  since  this  is  true  for  the  right  ventricle  as 
compared  with  the  left.  The  direct  estimation  of  blood-pres- 
sure in  the  pulmonary  artery  is  very  difficult,  without  produc- 
ing markedly  abnormal  conditions.  The  best  experiments  by 
Bentner,^  Lichtheim,^  Bradford  and  Dean,*  and  Knoll, ^  have 
shown  values,  as  compared  with  aortic  pressure,  between 
1 :  2.6  and  1 :  13.4.  These  were  in  the  rabbit,  dog,  and  cat.  In 
all  probability  it  does  not  average  more  than  one-fifth  the 
height  of  mean  aortic  pressure. 

•  Tschnewsky,  J.  A.  Ueber  Druck,  Geschwindigkeit  und  Widerstand  in 
Strombahn  der  Arteria  Carotis  und  Cruralis,  etc.  Arch.  f.  d.  gesam.  Physiol., 
1903,  vol.  xcvii,  pp.  263  and  270. 

2  Bentner,  A.  Ueber  die  Strom-  und  Druckkrafte  des  Blutes  in  der  Arteria 
und  Vena  pulmonalis.    Zeitschr.  f.  rat.  Med.,  1852,  vol.  ii,  pp.  106,  120. 

3  Lichtheim,  Ludwig.  Die  Storungen  des  Lungen  Kreislaufes  und  ihr 
Binfluss  auf  den  Blutdruck.  Breslau,  1876,  p.  31.  Quoted  by  Tigerstedt,  Lehr- 
buch,  p.  444. 

4  Bradford,  I.  R.,  and  Dean,  H,  P.  The  Innervation  of  the  Pulmonary 
Vessels.     Proceedings  of  the  Royal  Soc.  of  London,  1889,  vol.  xlv,  p.  370. 

*  Knoll,  Philipp.  Der  Blutdruck  in  der  Arteria  Pulmonalis  bei  Kaninchen 
und  seine  respiratorischen  Schwankungen.  Sitzungsber.  der  kais.  Akad.  der 
Wissensch.,  math,  naturw.  CI.,  1888,  vol.  xcvii,  Abth.  iii,  pp.  212,  214. 


32  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

The  most  recent  work  on  this  subject,  by  Tigerstedt/  has 
brought  out  a  number  of  facts  of  chnical  interest.  He  finds, 
for  the  rabbit,  that  the  maximum  pressure  in  the  right  ven- 
tricle shows  in  general,  when  large  pressure  variations  within 
the  thorax  are  excluded,  oifly  slight  fluctuation,  within  10  mm. 
From  individual  to  individual  it  differed  somewhat,  but  lay 
between  11  and  35  mm.  Even  the  great  narrowing  of  the 
cross-section  of  the  pulmonary  circulation,  which  was  produced 
by  opening  the  left  chest  and  tying  off  the  root  of  the  left 
lung,  affected  the  maximum  pressure  in  the  right  ventricle 
little  or  none,  and  caused  no  fall  of  mean  aortic  pressure. 
One-sided  pneumothorax  is  therefore  insufficient  to  raise  the 
work  of  the  right  heart,  and  the  mechanical  obstacle  to  the 
lesser  circulation  in  pneumonia  amounts  to  nothing.  He 
proves  further,  ' '  that  no  definite  relation  can  be  discovered 
between  the  mean  pressure  in  the  greater  circulation  and  the 
maximum  pressure  in  the  right  ventricle.  On  the  contrary 
the  former  can  vary  within  very  wide  limits  without  any  cor- 
responding change  in  the  other. " 

5.    THE    PERIODIC   VARIATIONS    OF    AORTIC 
BLOOD-PRESSURE 

As  we  saw  in  examining  the  normal  manometric  tracing 
(Fig.  1),  the  blood-pressure  is  undergoing  constant  oscillation 
above  and  below  a  certain  average  level.  Two  sets  of  these 
fluctuations  may  be  clearly  seen  in  the  trace,  the  more  rapid 
cardiac,  and  the  larger  respiratory  waves.  In  addition,  certain 
longer  but  slighter  rises  and  falls  of  the  whole  curve  may  be 
indistinctly  made  out,  the  so-called  Traube-Hering  waves. 
These  and  certain  other  variations,  which  are  of  regular  oc- 
currence in  physiological  experiment,  are  of  great  significance 
in  the  clinical  study  "of  blood-pressure  and  should  always  be 
in  mind.  They  will  bo  considered  in  the  order  of  their  impor- 
tance. 

A.  The  Cardiac  Variations— Systolic  and  Diastolic  Pressures.— 
Every  physician  who  feels  the  pulse  must  appreciate  that,  at 
the  moment  the  pulse-wave  strikes  the  finger,  the   pressure 

'  Tigerstedt,  R.  ITeber  den  Lungenkreislauf .  Skandinav.  Arch.  f.  Physiol., 
1903,  vol.  xiv,  pp.  267  and  285. 


VARIATIONS   OF   AORTIC   BLOOD-PRESSURE    33 

within  the  artery  is  raised  considerably,  falHng  again  after  the 
wave  has  passed.  In  the  perij^heral  arteries  this  occurs  an 
appreciable  time  after  the  systole  of  the  ventricles,  but  in  the 
aorta  the  maximum  and  minimum  of  pressure  correspond  ex- 
actly with  systole  and  diastole  of  the  heart.  We  may  then 
speak  of  the  highest  and  lowest  pressure  in  the  course  of  the 
pulse-wave  as  systolic  and  diastolic  pressure,  remembering 
that,  the  farther  we  go  from  the  heart,  the  less  synchronous 
these  are  with  the  events  in  the  cardiac  cycle  which  produce 
them.  Since  all  of  the  indirect  methods  for  determining 
blood-pressure  clinically  give  estimations,  more  or  less  accu- 
rate, of  either  systolic  or  diastolic,  but  never  of  mean  pres- 
sure, it  is  imperative  that  we  should  know  as  much  as  pos- 
sible of  the  absolute  amount  of  variation  within  one  cardiac 
cycle. 

Unfortunately,  as  we  have  seen,  the  mercurial  manometer 
gives  no  accurate  measure  of  such  rapid  fluctuations.  For 
this  purpose  the  various  forms  of  elastic  manometer  have  been 
employed,  none  of  them  absolutely  free  from  the  possibility  of 
error  due  to  their  own  vibrations,  but  giving  valuable  results. 
Very  few  reliable  data  are  available  on  this  question. 
Hiirthle,^  in  the  dog,  investigated  the  relation  of  systolic  and 
diastolic  pressure  in  different  arteries,  giving  several  tables, 
one  of  which  follows : 


PRESSURE  VARIATION  DURING  A  PULSE-WAVE  IN 

ARTERY. 

CAROTID. 

RENAL. 

FEMORAL. 

75-160 
78-158 
76-160 

80-156 
96-166 
94-166 

72-170 
75-165 
72-170 

80-164 
96-178 
96-178 

78-240 
80-235 

80-244 

90-225 
100-228 
100-230 

The  pressure  variations  here  recorded  are  the  largest  that 
have  been  observed,  averaging  over  100  per  cent  of  the  dia- 

^  Hiirthle,  K.     Ueber  den  Ursprungsort  der  sekundaren  Wellen  der  Puls- 
curve.     Arch.  f.  d,  ges.  Physiol.,  1890,  vol.  xlvii,  pp.  32-34. 
4 


34  BLOOD-PRESSURE   IN   THE   NORMAL   ANIMAL 

stolic  pressure.  Especially  striking  is  the  higher  systolic  pres- 
sure iu  the  femoral  than  in  the  carotid  artery,  which  Tiger- 
stedt  ^  considers  must  be  due  either  to  error  in  the  manometer, 
or  to  the  addition,  in  the  femoral,  of  a  primary  positive  reflected 
wave  to  the  pulse-wave.  Howell  and  Brush, ^  in  some  recent 
work  with  maximum  and  minimum  manometers,  were  unable 
to  find  such  extreme  differences,  except  after  section  of  both 


Mean 

pressure 

Mean 

directly 

Observa- 

Diastolic 

Systolic 

pressure 

deter- 

Rate per 

Ampli- 

tions. 

pressure. 

pressure. 

calcu- 
lated. 

mined  by 
mercury 
manom- 
eter. 

minute. 

tude. 

Exp.  X. 

Mm. 

Mm. 

Mm. 

Mm. 

Mm. 

I. 

133 

159 

146 

143.75 

96 

3.4 

II  > 

133 

107 

149.5 

144.93 

96 

1.75 

'  Severed  both 

Ill 

174 

301.5 

187.75 

183.87 

310 

3 

vagi. 

IV 

173 

199 

185.5 

183 

310 

3 

Exp.  XI. 

I.    

100 

150 

138 

137.49 

114 

9.83 

IP 

108 

150 

133 

139.3 

130 

8.4 

'  Severed  both 

Ill 

161 

190 

178.5 

177.4 

153 

5.6 

vagi. 

IV 

1C5 

315 

191.5 

185.46 

133 

6.9 

V 

133 

160 

146.5 

141.69 

133 

4.81 

VI 

134 

158.5 

141.35 

145.45 

136 

4.85 

Exp.  XII. 

I. 

113.5 

158.5 

135.5 

133.35 

87 

17.35 

II 

111 

159 

135 

133.9 

84 

17.7 

Ill 

110 

157 

133.5 

133.77 

84 

16.87 

IV 

113 

155 

135 

136 

83 

13.40 

v» 

113 

155 

134 

138.03 

84 

17.17 

*  Severed  vagi 

VI 

139 

140 

134.5 

134.5 

334 

1.35 

and      bled 

VII 

138 

140.5 

134.35 

130 

334 

1.35 

profusely. 

Exp.  XIII. 

I 

143 

336 

184.5 

183.86 

153 

8.5 

IT^    ... 

144 

310 

178 

169 

163 

8.5 

*  Severed  both 

Ill 

336 

373 

349 

333.5 

174 

10 

vagi. 

IV^ 

188.5 

358 

333.35 

336 

171 

10 

^  Severed    left 

V« 

101 

137 

119 

134.75 

163 

5.35 

splancliiiic. 

VI 

37 

68.35 

53.63 

47.33 

163 

3.7 

*  Severed  right 

VII 

36 

70 

53 

51.75 

163 

3.7 

sijlaiiclinic. 

VIII.... 

35 

71 

53  35 

53 

103 

4 

IX 

38.5 

74 

56.35 

50.83 

103 

4 

X 

41 

79 

60 

53.83 

163 

3.9 

XI 

45.5 

78 

61.75 

57.34 

163 

3 

*  Tigerstedt,  Lehrbuch,  p.  353. 

^  IIowoll,  W.  II.,  and  Hni.sh,  C.  K.,  Jr.  A  Critical  Note  upon  Clinical  Meth- 
ods of  measuring  Blood-jircssure.  Boston  Med.  and  Surg.  Jour.,  1901,  vol.  cxlv, 
p.  146. 


VARIATIONS   OF   AORTIC   BLOOD-PRESSURE    35 

splanchnics.      Under  normal  conditions,  twenty  observations 
on  dogs  gave 

Greatest  difference 58  per  cent,  of  the  diastolic  pressure. 

Smallest  difference 17  per  cent,  of  the  diastolic  pressure. 

Average  difference 33  per  cent,  of  the  diastolic  pressure. 

In  man,  with  his  slower  heart  rate,  they  believe  the  differ- 
ence must  be  greater.  They  also  tabulate  (see  page  34)  some  in- 
teresting figures  on  the  relation  of  systolic,  diastolic,  and  mean 
pressures.     From  these  they  draw  the  following  conclusions : 

"  1 .  The  mean  blood-pressure,  as  usually  determined  by 
means  of  the  mercury  manometer,  corresponds  with  fair  accu- 
racy to  the  arithmetical  mean  of  the  maximum  and  minimum 
pressures." 

"3.  A  rise  of  blood-pressure  occasioned  by  an  increased 
heart  beat  (section  of  both  vagi)  affects  the  diastolic  pressure 
to  a  greater  extent  than  the  systolic  pressure." 

"3.  A  fall  of  blood-pressure  occasioned  by  vascular  dilata- 
tion (section  of  both  splanchnics)  affects  systolic  and  diastolic 
pressures  equally." 

"4.  It  is  possible  for  the  systolic  and  diastolic  pressures 
to  be  affected  in  opposite  directions,  as  seen  in  Exp.  XII,  in 
which  section  of  both  vagi  was  intentionally  accompanied  by 
profuse  haemorrhage.  In  this  case  the  mean  pressure  re- 
mained unchanged,  the  diastolic  pressure  rising  16  mm.  and 
the  systolic  pressure  falling  15  mm." 

They  believe,  even  for  physiological  purposes,  that  a  record 
of  systolic  and  diastolic  pressure  would  be  more  instructive 
than  the  ordinary  mean  pressure.  They  think  their  experi- 
ments indicate,  so  far  as  they  go,  that  even  under  extreme 
conditions  of  cardiac  and  vascular  change,  unless  accompanied 
by  haemorrhage,  the  general  trend  of  arterial  pressure  is 
shown  either  in  systolic  or  diastolic  pressure. 

These  problems,  in  the  light  of  their  great  importance  to 
clinical  sphygmomanometry,  deserve  careful  study.  The  vari- 
ous attempts  to  solve  them  by  clinical  methods  I  will  not  con- 
sider here,  for  their  results  have  not  absolute  value. 

B.  The  Respiratory  Variations. — The  relationship  of  aortic 
blood-pressure  to  the  inspiratory  and  expiratory  acts  is  too 
complex  for  full  discussion,  and  is  totally  different  in  the  nor- 
mal animal  and  in  one  in  which  the  thorax  has  been  opened. 


36  BLOOD-PRESSURE   IN   THE  NORMAL  ANIMAL 

In  the  latter,  the  varying  caHbre  of  the  smaller  pulmonary 
vessels  is  the  only  factor  concerned,  and  the  blood-pressure  is 
highest  in  the  first  half  of  inspiration  and  lowest  in  the  first 
half  of  expiration,  because  the  largest  and  smallest  amounts  of 
blood  are  brought  to  the  left  ventricle  at  these  times.  In  the 
healthy  animal,  however,  breathing  spontaneously,  there  is 
added  to  this  the  aspirating  force  of  inspiration  for  the  blood 
in  the  great  veins;  the  changes  in  the  elastic  pull  of  the  lungs 
upon  the  heart,  making  systole  more  difficult  and  facilitating 
diastole,  and  upon  the  great  vessels,  alternately  widening  and 
narrowing  them ;  and  the  changes  in  intra-abdominal  pressure, 
influencing  the  blood-flow  to  the  right  heart.  Besides  all  these, 
there  are  rhythmical  variations  in  the  activity  of  the  vagus  and 
vaso-motor  centres  in  the  medulla,  synchronous  with,  and  in 
some  way  related  to,  the  activity  of  the  respiratory  centre. 
Both  show  a  greater  tonus  during  expiration,  the  heart  rate 
becoming  slower  and  the  peripheral  resistance  higher;  thus 
their  effect  upon  blood-pressure  is  antagonistic. 

The  result  of  the  interaction  of  these  various  conditions, 
some  tending  to  raise  and  some  to  lower  pressure,  depends 
upon  the  depth  and  rapidity  of  respiration.  According  to 
Tigerstedt,^  during  quiet,  superficial  breathing 
the  blood-pressure  shows  no  variations.  With 
more  forcible  and  rapid  breathing  the  pressure 
rises  during  expiration  and  falls  during  inspira- 
tion; while  with  deeper  and  slower  respiration 
the  maximum  pressure  coincides  with  the  begin- 
ning of  expiration,  the  minimum  with  the  be- 
ginning of  inspiration.  In  the  latter  case  the 
pulse  frequency  is  also  increased  during  inspi- 
ration. This  summary  at  once  suggests  its  most  important 
clinical  application,  which  is  to  make  all  pressure  estimations 
during  quiet,  unforced  breathing. 

C.  The  Traube-Hering  Waves. — This  name  is  given  to  certain 
periodic  rises  and  falls  in  blood-pressure,  which  embrace  several 
respiratory  periods.     They  were  first  noted  by  Traube^  and 

1  Tigerstedt,  Lehrbuch,  p.  462. 

*  TrauVje,  L.  Ueber  periodische  Thatigkeitsiiusserungen  des  vasomoto- 
rischen  und  Ilemmungs-Nervensystems.  Centralblatt  f.  d.  med.  Wissensch., 
1865,  vol.  iii,  p.  882. 


INFLUENCE   ON   BLOOD-PRESSURE  37 

are  evident  in  all  prolonged  pressure  observations.  According 
to  Knoll  ^  they  correspond,  as  a  rule,  with  similar  rhythmical 
variations  in  the  depth  of  respiration,  and  are  therefore,  in  all 
probability,  due  to  periodic  changes  in  the  tonus  of  the  vaso- 
motor and  respiratory  centres.  They  must  be  borne  in  mind  in 
all  clinical  observations,  since  changes  of  several  millimeters 
in  pressure,  at  the  least,  may  be  due  to  them. 

6.  SPONTANEOUS   NON-RHYTHMICAL  VARIATIONS 
OF  AORTIC  BLOOD-PRESSURE 

In  many  experiments,  changes  in  pressure  of  moderate  ex- 
tent are  noted  from  time  to  time  without  assignable  cause. 
As  we  have  seen,  the  vaso-motor  centre  responds  by  a  vascu- 
lar reflex  upon  stimulation  of  any  sensory  nerve,  and  these 
apparently  spontaneous  variations  in  blood-pressure  may  be 
reflex,  or  they  may  be  due  to  changes  within  the  central  nerv- 
ous system.  One  must  be  warned  of  their  occurrence,  as  of 
the  Traube-Hering  waves,  in  order  that  they  may  not  be  inter- 
preted as  proving  the  success  or  failure  of  therapeutic  pro- 
cedures. 

7.    THE  INFLUENCE  OF  ASPHYXIA  ON   BLOOD- 
PRESSURE 

If  an  animal  be  deprived  of  oxygen,  phenomena  ensue 
which  produce  the  picture  we  call  asphyxia.  If  the  depriva- 
tion be  sudden,  as  on  tying  off  the  trachea,  death  occurs  inside 
of  five  minutes  and  is  preceded  by  convulsions.  Where  suffo- 
cation is  more  gradual,  as  in  a  closed  chamber,  the  convul- 
sions do  not  appear  and  Life  is  more  prolonged.  In  addition  to 
the  motor  and  respiratory  manifestations  of  dyspnoea,  how- 
ever, there  is  a  striking  effect  upon  the  vaso-motor  and  vagus 
centres.  In  the  first  stage,  during  which  the  respiratory 
centre  is  stimulated  and  the  breathing  is  rapid  and  deep,  the 
vaso-motor  centre  in  the  medulla  is  also  thrown  into  action 
and  a  marked  rise  in  blood-pressure  occurs.  This  is  accom- 
panied by  increasing  slowness  of  the  pulse  from  simultaneous 

1  Knoll,  P.  Ueber  periodische  Athmungs  und  Blutdruckschwankungen. 
Sitzungsber.  d.  kais.  Akad.  d.  Wiss.,  math,  naturw.  CI.  1885,  vol.  xcii,  pp 
443-447. 


38  BLOOD-PRESSUKE   IN   THE   NORMAL  ANIMAL 

activity  of  the  vagus  centre.  In  the  later  stages,  as  the  irri- 
tabihty  of  the  respiratory  centre  becomes  exhausted,  the  other 
bulbar  centres  likewise  fail ;  then  the  spinal  vaso-motor  centres 
begin  to  act  and  the  blood-pressure  is  maintained  at  a  high 
level,  with  increasing  heart-rate  and  spasmodic,  ineffectual  res- 
piratory acts,  only  to  fall  during  the  last  seconds  of  life, 
when  the  spinal  centres  have  become  utterly  exhausted.* 
This  extreme  rise  of  blood-pressure  caused  by  asphyxia  and, 
in  a  lesser  degree,  by  slighter  grades  of  deficient  oxygenation 
of  the  blood,  is  of  distinct  clinical  import,  as  in  the  study  of 
arterial  pressure  in  cardiac  and  lung  conditions,  laryngeal 
diphtheria,  etc. 

8.    THE    INFLUENCE   OF  ATMOSPHERIC    PRESSURE 
ON   BLOOD-PRESSURE 

The  striking  parallelism  between  the  blood-pressure  and 
the  external  pressure  to  which  the  body  is  subjected,  has  been 
exhaustively  studied  by  Crile,^  and  his  results  are  of  the 
greatest  interest  in  connection  with  the  treatment  of  surgical 
shock.  He  has  shown  in  many  experiments  a  rise  in  pressure 
in  practically  all  the  arteries  of  the  body  when  the  surround- 
ing pressure  is  increased,  in  diastolic  pressure  apparently  more 
than  systolic.  The  rise  is  proportional  to  the  height  of  the 
external  pressure,  and  occurs  equally  after  division  of  the  cer- 
vical cord.  It  is  therefore  a  direct  mechanical  effect,  and  not 
due  to  reflex  vaso-constriction.  It  is  least  in  the  arteries 
within  the  bony  cavities  of  cranium  and  thorax.  The  height 
at  which  the  pressure  will  be  maintained  depends  only  on  the 
reserve  force  of  the  heart.  He  observed  a  corresponding  fall 
on  diminishing  atmospheric  pressure.  This  effect  of  rarefied 
air  was  more  thoroughly  studied  by  Lazarus  and  Schirmun- 
ski,^  who  found,  not  only  a  uniform  sinking  of  carotid  pressure 
with  the  atmospheric  pressure,  but  a  continuance  of  the  low 

*  A  diagram  illustrating  the  effect  of  asphyxia  on  the  various  nerve  centres 
may  be  found  in  Tigerstedt's  Lehrbuch  der  Physiologie  des  Menschen,  second 
edition,  1902,  vol,  ii,  p.  298. 

»  Crile,  George  W.  Blood-pressure  in  Surgery.  Philadelphia,  1903,  pp. 
283-286. 

•  Lazarus  und  Schirmunski.  Ucber  die  Wirkung  des  Aufenthalts  in  Ver- 
diinnter  Luft  auf  den  Blutdruck.      Zeitschr.  f.  klin.  Med.,  1884,  vol.  vii,  p.  299, 


INFLUENCES   ON   BLOOD-PRESSURE  39 

pressure  for  a  time  after  normal  conditions  had  been  restored. 
Only  when  pronounced  muscular  twitching  occurred  did  they 
miss  the  fall. 

Crile's  experiments  on  the  effects  of  breathing  air  at  dif- 
ferent pressures  were  inconclusive  because  too  great  and  sudden 
changes  were  produced.  Bartlett  ^  has  investigated  the  effects 
of  breathing  rarefied  air  in  rabbits.  He  finds  that  the  aortic 
pressure  falls  with  that  of  the  inspired  air,  after  a  sufficient 
negative  pressure  has  been  reached.  The  point  at  which  the 
drop  begins  varies,  in  different  individuals,  between  10  and  15 
mm. ,  and  is  marked  at  a  pressure  of  — 15  to  —  25  mm.  At  these 
lower  figures  the  pulmonary  circulation  is  slowed  and  stagna- 
tion in  the  capillaries,  with  lung  swelling,  occurs. 

9.   THE  INFLUENCE  OF  MUSCULAR  WORK  ON 
BLOOD-PRESSURE 

The  conditions  of  direct  manometric  measurement  are  not 
compatible  with  much  exertion  on  the  part  of  the  animal,  and 
little  experimental  evidence  on  the  subject  exists.  Marey^ 
taught  that  work  lowered  pressure,  quoting  an  experiment  on 
a  horse,  in  which  a  run  of  ten  minutes  reduced  the  mean  carotid 
pressure  from  108  mm.  to  102  mm.,  an  insignificant  difference. 
For  such  a  fall  to  occur,  vascular  dilatation  would  have  to  be 
more  marked  than  the  increase  of  cardiac  energy. 

Tangl  and  Zunst  ^  have  succeeded  in  obtaining  trustworthy 
results  in  a  few  dogs.  These  were  made  to  run  up  steps,  and 
the  maximum  and  minimum  carotid  pressures  measured  at  in- 
tervals. From  these  the  absolute  mean  pressure  was  calculated. 
They  found  a  uniform  rise  in  mean  pressure  of  6  to  23  mm. 
Very  fast  running  caused  an  extreme  elevation,  in  two  instances 
from  115  mm.  to  235  mm.,  and  from  120  mm.  to  242  mm., 
respectively.  There  seems  no  reason  to  question  their  general 
results,  which  prove  the  usual  tendency  of  muscular  work  to 
raise  pressure. 

'  Bartlett,  Frederic  H.  On  the  Variations  of  Blood-pressure  during  the 
Breathing  of  Rarefied  Air.     Am.  Jour,  of  Physiol.,  1903,  vol.  x,  p.  143. 

*  Marey,  B.  J.  La  circulation  du  sang  a  I'etat  physiologique  et  dans  les 
maladies.     Paris,  1881,  p.  348. 

^  Tangl,  F.,  und  Zunst,  N.  Ueber  die  Einwirkung  der  Muskelarbeit  auf  den 
Blutdruck.     Arch.  f.  d.  gesam.  Physiol.,  1898,  vol.  Isx,  p.  544. 


PART  IL— TECHNICAL 


CHAPTER  III 

THE   INDIRECT   MEASUREMENT  OF  BLOOD-PRESSURE 

1.  Introduction. 

A.  The  palpation  of  the  pulse.     Methods  of  judging  ten- 

sion and  their  defects. 

B.  Sphygmographic  methods  of  estimating  blood-pressure. 

C.  Other  methods  which  apply  pressure  through  a  solid 

block. 

2.  The  development  of  sphygmomanometers  applying  pressure  to 

the  artery  through  a  fluid  medium. 

A.  The  instrument  of  v.  Basch,  determining  the  pressure 

necessary  to  obliterate  the  pulse  (systolic  pressure), 
and  Potaiix's  modification, 
a.  Errors  of  the  v.  Basch  and  Potain  sphygmomanometers. 

B.  The  origin  of  sphygmomanometers  registering  maxi- 

mum pulsation  (diastolic  pressure). 

a.  Marey's  first  instrument.     Hiirthle's  elaboration. 

b.  Marey's  second  instrument. 

c.  Mosso's  apparatus. 

d.  Oliver's  hsemodynamometer. 

e.  Hill  and  Barnard's  pocket  sphygmometer. 

C.  Change  in  color  of  the  skin  as  a  means  of  determining 

systolic  pressure. 

3.  The  method  of  circular  compression  by  air  (Riva-Rocci.  Hill). 

41 


42  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

4.  Experimental  verification  of  the  method  of  circular  compression. 

A.  Influence  of  the  inner  wall  of  the  tube, 
a.  Influence  of  faulty  adjustment. 

B.  Influence  of  the  tissues. 

a.  Relation  of  width  of  armlet  to  circumference  of  limb.    (v.  Reck- 

linghausen.) 

b.  Influence  of  the  site  of  application. 

c.  Influence  of  the  vessel  wall. 

d.  Influence  of  muscular  contraction. 

e.  Influence  of  oedema. 

C  Conclusions. 

5.  Validity  of  the  several  criteria. 

A.  Of  systolic  pressure. 

a.  The  return  of  the  pulse  wave  under  compression. 

b.  The  return  of  color  to  the  skin  of  the  blanched  finger. 

c.  Comparison  of  systolic  pressures  in  brachial  and  digital  arteries. 

B.  Of  diastolic  pressure. 

a.  Maximum  pulsation  of  the  arterial  wall. 

C.  Other  criteria,  not  in  clinical  use. 


CHAPTER   III 
THE  INDIRECT  MEASUREMENT  OP   BLOOD-PRESSURE 

1.    INTRODUCTION 

The  impetus  which  Ludwig's  invention  of  the  kymographion 
gave  to  the  study  of  circulatory  physiology  soon  made  itself 
felt  in  the  field  of  clinical  medicine.  The  introduction  of  the 
sphygmograph,  which  could  be  applied  to  the  living  patient, 
enhanced  this  interest,  and  the  investigation  of  the  finer  char- 
acters of  the  pulse  seemed  about  to  yield  valuable  practical 
results.  How  little  it  has  fulfilled  that  early  hope  we  know. 
With  the  sphygmograph,  however,  came  the  first  attempt  to 
measure  human  blood-pressure,  made  by  K.  Vierordt  in  1855. 
The  distinction  between  the  hard  and  the  soft  pulse  had  been 
made  before,  but  from  that  day  the  terms  acquired  a  new  sig- 
nificance, and  the  clinic  set  itself  the  task  of  finding  some 
means  for  assigning  them  a  quantitative  value,  comparable 
with  the  results  of  the  physiological  laboratory.  The  history 
of  the  successive  methods  is  a  long  one,  not  always  free  from 
rancor  and  jealousy,  when  a  cherished  instrument  has  done  its 
best  service  in  the  unexpected  way  of  suggesting  a  more  perfect 
one;  but  more  and  more  objective  determinations  have  fol- 
lowed one  another,  until  to-day  the  intelligent  physician  can  no 
more  afford  to  dispense  with  some  form  of  sphygmomanometer, 
in  the  study  of  certain  types  of  disease,  than  he  could  discard 
the  thermometer  and  trust  his  trained  sense  of  touch,  to  detect 
the  variations  of  body  temperature  in  a  case  of  typhoid  fever. 
That  sphygmomanometry  has  the  wide  range  of  applicability 
or  the  importance  of  clinical  thermometry,  not  even  its  most 
enthusiastic  advocate  would  claim;  but  that  we  now  possess 
several  instruments,  of  sufficient  accuracy  and  such  ease  of 
application,  as  to  make  their  routine  use  a  necessity  for  the 
educated  and  conscientious  practitioner,  seems  to  me  proven. 

43 


44  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

A.  The  Palpation  of  the  Pulse. — Methods  of  Judging  Pressure 
and  their  Defects. — The  main  ground  for  such  a  belief  lies  in 
the  extreme  fallaciousness  of  that  time-honored  method,  the 
palpation  of  the  pulse,  as  a  means  of  estimating  the  blood- 
pressure.  How  erroneous  our  former  judgments  were  in  this 
respect,  the  use  of  a  sphygmomanometer  for  a  few  days  will 
convince  any  one.  The  reason  for  it  is  simple  and  the  cause  is, 
from  the  nature  of  the  method,  unavoidable.  Two  ways  of 
estimating  the  tension  of  the  pulse  are  in  vogue.  The  first 
consists  in  compressing  the  artery  with  the  finger,  until  the 
pulse  can  be  no  longer  perceived  by  a  second  finger,  placed  on 
the  artery  just  below.  From  the  considerations  on  page  10, 
it  is  plain  that  this  is  an  attempt  to  test  the  systolic  end  pres- 
sure. The  other  procedure  is,  to  increase  gradually  the  pres- 
sure of  the  finger,  or  better  fingers,  upon  the  artery,  noting 
the  change  in  the  pulse-wave  all  the  while.  In  pulses  of  high 
tension,  the  size  of  the  wave  will  be  felt  to  increase  with  in- 
creasing pressure  up  to  a  certain  point,  diminishing  only  when 
considerable  force  is  used;  whereas,  with  normal  or  low  ten- 
sion, the  amplitude  of  the  pulse  is  reduced  with  very  little  ap- 
plication of  pressure.  In  this  way  a  knowledge  of  the  diastolic 
lateral  pressure  is  obtained,  for  reasons  which  will  be  discussed 
fully  in  connection  with  the  instruments  which  measure  this. 
In  many  patients,  the  larger  variations  in  arterial  pressure  may 
be  readily  detected  by  either  method,  the  latter  being  some- 
what preferable,  because  less  afi^ected  by  the  amount  of  tissue 
overlying  the  artery.  Both  fail,  however,  in  a  crucial  point. 
Our  muscular  sense,  upon  which  depends  our  judgment  of  the 
amount  of  pressure  used,  takes  cognizance  only  of  the  total 
amount  of  force  expended,  not  at  all  of  such  a  mathematical 
ratio  as  amount  of  force  to  the  unit  of  surface.  Were  arteries, 
or  even  radial  arteries,  all  of  equal  calibre,  the  two  quantities 
would  be  identical.  Unfortunately  there  are  not  only  wide 
variations  in  size  in  different  individuals,  but,  in  one  and  the 
same  person,  the  radial  or  temporal  artery  changes  in  diameter 
markedly  under  varying  local  conditions.  Since  the  total 
force  exerted  is  proportional  to  the  extent  of  surface  of  the 
artery,  as  well  as  to  the  pressure  per  unit  surface  within  it  (by 
Pascal's  law),  the  larger  the  artery,  the  higher  we  shall  think 
the  pressure.     This  will  be  readily  appreciated  by  any  one,  who 


SPHYGMOGRAPHIC   METHODS  45 

will  attempt  to  compare  the  apparent  pressures  in  the  radial 
and  in  the  abdominal  aorta,  which,  in  reality,  are  nearly  equal. 
It  is  also  evident  that  our  failure  to  detect  increased  pressure  by 
the  finger  will  be  most  unavoidable  in  the  small,  so-called  wiry 
pulse,  which  often  connotes  an  extreme  grade  of  high  tension. 

B.  Sphygmographic  Methods  of  Estimating  Blood-pressure. — 
Following  Vierordt's  ^  lead,  more  elaborate  adjustments  of 
weights  in  connection  with  Marey's  sphygmograph  were  made 
by  Forster,  Landois,  and  Behier.  Even  as  recently  as  1897, 
Philadelphien  devised  his  so-called  "  sphygmometrographe," 
and  Levaschoff,^  in  1901,  employed  a  somewhat  similar 
method.  These  instruments  are  of  purely  historic  interest, 
for  the  sphygmograph  is  an  instrument  whose  results  are 
notoriously  subjective,  and  dependent  upon  the  observer  who 
applies  it.  Apart  from  this,  the  pressure,  in  all  of  them,  was 
applied  to  the  artery  through  a  solid  block,  and  therefore  they 
measure  total  pressure,  as  does  the  finger;  not  pressure  per 
unit  of  surface.  They  served,  however,  to  estab- 
lish one  criterion,  as  a  measure  of  blood-pres- 
sure; viz.,  the  pressure  at  which  the  pulse-wave 
is  obliterated.  This,  we  have  seen,  gives  the 
systolic  end  pressure,  since  it  is  equivalent  to  attaching 
a  manometer  to  the  end  of  the  artery  at  the  point  of  compres- 
sion.    (See  page  11.) 

C.  Other  Methods  which  Apply  Pressure  through  a  Solid 
Block. — ^Waldenburg  in  1877,  and  later  Bloch,  Verdin,  Cheron, 
and  Hoorweg,^  brought  forward  different  forms  of  apparatus, 
which  all  possess  the  same  fatal  defect  of  applying  the  pres- 
sure to  the  artery  through  a  solid  medium.  Within  a  few 
years  v.  Frey  has  added  to  this  list  another,  which  requires 
twenty  minutes  for  a  single  observation.* 

1  All  methods  described  in  this  chapter,  for  which  no  references  are  given, 
may  be  found  in  the  elaborate  historical  articles  of  N.  Vaschide  and  J.  M. 
Lahy,  La  technique  de  la  mesure  de  la  pression  sanguine.  Arch.  gen.  de 
Medecine,  1903,  vol.  ii,  pp.  349-383,  480-501  and  602-639. 

5  Levaschoff,  I.  K     Vratch,  St.  Petersburg,  1901,  vol.  xxii,  pp.  1433  and  1471. 

^  Hoorweg,  J.  L.  Ueber  die  Blutbevvegung  in  den  menschlichen  Arterien. 
Arch.  f.  d.  gesam.  Physiol.,  1889,  xlvi,  p.  166. 

"*  Hayaski,  T.  Vergleichende  Blutdruckmessungen  an  Gesunden  und 
Kranken  rait  den  Apparaten  von  Gartner,  Riva-Rocci  und  Frey.  Inaug.  Dis- 
sert., Erlangen,  1901,  Dec. 


46  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 


2.    THE  DEVELOPMENT  OF  SPHYGMOMANOMETERS 

APPLYING    PRESSURE  TO    THE  ARTERY 

THROUGH  A  FLUID   MEDIUM 

A.  The  Instrument  of  v.  Basch,  Determining  the  Pressure 
Necessary  to  Obliterate  the  Pulse  (Systolic  Pressure),  and  Potain's 
Modification. — The  first  man  to  perfect  a  sphygmomanometer 
suitable  for  clinical  use,  and  free  from  gross  inaccuracy,  was 

Prof.  V.  Basch  of  Vienna. 
In  1876  he  constructed  his 
apparatus,  which  in  its  origi- 
nal form  is  shown  in  Fig.  7. 
In  two  fundamental  respects 
it  differed  from  all  that  had 
preceded  it.  One  was  the 
employment  of  a  bag  con- 
taining fluid  as  the  com- 
pressing mechanism,  thus 
obtaining  pressure  per  unit 
of  surface  for  the  first  time; 
the  other  was  the  use  of  a 
mercury  manometer  for  the 
measurement  of  the  pressure 
within  the  bag  necessary  to 
wholly  compress  the  artery. 
In  this  way  he  made  possible 
a  comparison  of  results  with 
the  direct  estimations  of  the 
physiologist. 

The  essential  parts  of  the 
V.  Basch  sphygmomanome- 
ter are  seen  in  the  cut.  B  is 
the  so-called  pelotte,  origi- 
nally a  glass  funnel  covered 
with  an  elastic  membrane, 
only  slightly  stretched.  The  pelotte  is  connected  with  the  ma- 
nometer (A)  by  non-distensible  tubing  and  a  T-canula  (D). 
The  vertical  branch  leads  to  a  funnel  (C),  through  which  the 
pelotte  and  tubing  are  filled  with  water.  At  E  is  a  pinch-cock, 
by  which  this  communication  can  be  cut  off,  after  the  mercury 


Fio.  7. — V.  Basch's  sphvomomanometer. 
First  model. 


DEVELOPMENT   OF   SPHYGMOMANOMETERS    47 

has  come  to  equilibrium  and  the  zero  point  of  the  manometer  has 
been  determined.  The  mode  of  apphcation  is  as  follows:  An 
artery,  temporal  or  radial,  is  selected,  which  lies  closely  upon 
bone,  and  pressure  is  made  over  it  with  the  pelotte,  care  being 
taken  that  the  compression  shall  be  directly  against  the  bone. 
As  the  pressure  is  increased,  water  is  forced  out  of  the  pelotte 
into  the  closed  arm  of  the  manometer,  which  at  each  moment 
registers  the  exact  pressure  exerted  over  the  artery.  The 
pulse  is  felt  with  a  finger  of  the  opposite  hand,  just  beyond 


Fig.  8. — v.  Basch's  sphygmomanometer. 
Eecent  model. 


the  point  of  compression,  or  made  visible  by  a  lever  held  over 
the  artery  by  a  rubber  bracelet.  Just  at  the  moment  when  it 
disappears,  or,  as  most  prefer,  when  it  first  returns  as  the 
pressure  is  lowered,  the  manometer  is  read  off.  This  reading 
gives  the  pressure  in  millimeters  of  mercury  necessary  to 
obliterate  the  artery;  that  is,  the  systolic  end  pressure,  plus 
certain  other  factors,  which  will  be  considered  shortlj'. 

The  original  instrument  of  v.  Basch  has  undergone  numer- 
ous modifications  at  his  own  hands  and  others.  The  most 
important  were  his  introduction  of  a  portable  metal  manom- 


48  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 


eter,  and  the  change  in  the  pelotte,  as  shown  in  Fig.  8 ;  and, 
in  1889,  Potain's  replacement  of  the  water  by  air,  the  pressure 
of  which  is  raised  by  a  bulb  connected  with  the  circuit  through 
an  extra  branch  tube.  Potain's  sphygmomanometer,  as  shown 
in  Fig.  9,  was  the  basis  of  his  extended  clinical  researches 
into  arterial  pressure,^  and  has  a  wide  vogue  m  France;  while 


Fig.  9. — Potain's  sphygmomanomkteb. 

the  V.  Basch  instrument  is  still  stoutly 
defended  against  all  new-comers  by  its 
inventor  and  his  pupils  of  the  Vienna 
school.  To  them  belongs  the  great  honor  of  the  pioneer  work 
in  the  field  of  chnical  sphygmomanometry,  and  to  their  efforts 
we  owe  the  recognition  of  its  value;  but  the  lack  of  earlier 
acceptance  by  physicians  in  general  was  due  to  distrust  of  the 
absolute  value  of  the  results  obtained  with  the  instrument, 
and  to  the  skill  required  for  its  use.  v.  Basch  will  always  be 
remenibered  as  the  inventor  of  clinical  sphygmomanometry, 
but  his  method  rhust  give  place  to  its  simpler  and  more  accu- 
rate offspring. 

•  Potain.    La  pression  art^rielle  de  ITiomme  h  I'etat  normal  et  patholo- 
gique,  Paris,  Masson,  1902. 


DEVELOPMENT   OF   SPHYGMOMANOMETERS   49 

A.  Errors   of  the  v.  Basch  and  Potain  Sphygmomanometers. — 

These  are  due,  not  to  defects  in  the  instrument  itself,  but  to 
the  method  of  its  apphcation.  It  measures  the  pressure  neces- 
sary to  obhterate  the  kimen  of  the  artery.  Were  the  artery 
exposed,  with  no  overlying  tissue,  and  placed  directly  against 
the  bone,  this  would  equal  the  systolic  end  pressure  plus  the 
pressure  required  to  close  the  empty  artery.  This,  according 
to  V.  Basch,  for  the  normal  radial  scarcely  amounts  to  1  mm. 
and  even  for  sclerotic  arteries  is  not  much  above  5  mm.^ 
There  may  also  be,  v.  Basch  admits,  a  difference  of  5  mm.  be 
tween  the  point  of  disappearance  of  the  pulse-wave  and  itc 
return.  In  the  living  patient,  however,  the  artery  is  covered 
by  skin  and  a  varying  amount  of  adipose,  which  the  author 
considers  require  6  to  8  mm.  additional  pressure.  These  causes 
of  over  estimation,  since  they  are  small  and  more  or  less  con- 
stant, and  also  because  they  must  be  present  in  any  clinical 
method  which  gives  systolic  end  pressure,  could  not  be  con- 
sidered serious. 

The  damaging  evidence,  which  v.  Basch  himself  gives,  re- 
lates to  the  effect  of  the  varying  position  of  the  artery  with 
reference  to  the  bone.  Only  rarely  did  he  find  the  pressure 
in  temporal  and  radial  nearly  alike,  in  most  cases  the  radial 
requiring  20  mm.,  and,  in  exceptionally  badly  placed  ones, 
60  mm.  more  for  its  compression.  These  readings  were  made  by 
practised  observers,  and  in  unskilled  hands  would  make  a  far 
worse  showing.  Potain,  in  his  book  (p.  36),  cites  several  cases 
as  showing  the  great  difference  in  pressure  which  may  exist 
in  different  arteries  at  the  same  moment.  One,  a  young  girl, 
gave  5.5  cm.  for  the  temporal,  16.5  cm.  for  the  radial;  an 
adult,  12.5  cm.,  temporal;  19.5  cm.,  radial;  and  17  cm.,  dorsalis 
pedis.  He  observed  differences  of  0.5  to  2  cm.  between  the 
two  radial  arteries.  These  figures  contradict  our  established 
physiological  knowledge  concerning  the  pressure  in  different 
arteries  (see  page  30),  and  are  unquestionably  due  to  errors 
inherent  in  the  method  and  to  variations  in  the  position  of  the 
artery,  so  that  the  pressure  is  not  always  applied  directly  over 
it  and  against  the  bone. 


'  V.  Basch,  S.     Der  Sphygmomanometer  uiid  seine  Verwerthung  in  der 
Praxis.     Berl.  klin.  Wochenschr.,  1887,  vol.  xxiv,  p.  181. 
5 


50  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

Tigerstedt  ^  sums  up  these  sources  of  error  from  v,  Basch's 
figures  as  follows : 

Lowest  estimate ;  1  -|-  5  +  6  +  20  mm.  =  32  mm.  overestimation. 

In  unfavorable  cases ;  5  -|-  5  +  8  -j-  60  mm.  =  78  mm.  " 

He  concludes,  and  rightly,  that  the  absolute  values  found  with 
such  instruments  can  have  no  significance,  but  that  they  are 
suited  to  the  estimation  of  the  pressure  changes  which  occur 
in  the  same  individual,  within  reasonable  periods  of  time. 

I  have  gone  thus  at  length  into  this  subject,  because  one 
must  exercise  a  similar  criticism  in  the  results  of  all  other 
methods  of  indirect  blood-pressure  determination,  in  each  of 
which  some  of  the  same  sources  of  overestimation  are  oper- 
ative. 

B.  The  Origin  of  Sphygmomanometers  Registering  Maximum 
Pulsation  (Diastolic  Pressure). — a.  Marey's  First  Instrument. — 
Hiirthle's  Elaboration. — At  the  same  time  that  v.  Basch  brought 
out  his  instrument,  Marey  carried  on  experiments  in  his  labo- 
ratory, from  which  our  clinical  methods  of  determining  dia- 
stolic pressure  have  been  developed.  From  them,  besides, 
have  come  the  plethj^smograph  and  its  congeners. 

Marey's  observations  were  upon  the  effect  of  compressing 
the  blood-vessels  from  all  sides,  instead  of  from  a  single  sur- 
face. His  first  apparatus  was  a  tight  metal  box,  filled  with 
water,  and  large  enough  to  hold  the  fore-arm  and  hand  inserted 
through  a  rubber  collar,  which  entirely  closed  the  opening. 
The  box  was  connected  with  a  mercury  manometer  and  a  re- 
cording tambour,  as  well  as  with  a  reservoir,  by  means  of 
which  the  pressure  could  be  gradually  raised.  A  glass  win- 
dow afforded  a  view  of  the  enclosed  hand.  Marey  noted  that, 
as  the  pressure  within  the  box  was  raised,  the  pulse  waves  be- 
came transmitted  to  the  fluid  and  thus  to  the  tambour.  These 
pulsations  increased  in  amplitude  up  to  a  certain  point,  then 
gradually  declined  again.  Long  before  they  had  entirely 
ceased,  however,  the  skin  of  the  hand  was  seen  to  blanch,  thus 
showing  that  the  vessels  had  been  collapsed  and  their  systolic 
pressure  overcome.  Marey  reasoned  that,  at  the  moment 
when  the  pulsations  reached  their  maximum,  the  external 
pressure  must  be  just  equal  to  that  within  the  blood-vessels; 

'  Tigerstedt.     Lehrbuch  d.  Physiol,  des  Krcislaufes,  Leipzig,  1893,  p.  331. 


DEVELOPMENT   OF  SPHYGMOMANOMETERS    51 

their  walls,  being  thus  relieved  of  any  tension  on  either  side, 
would  execute  their  maximum  oscillations.  He  proposed  this 
as  a  new  criterion  for  the  indirect  measurement 
of  blood -pressure;  the  external  pressure  at 
which  maximum  pulsation  of  the  arterial  walls 
occurs.^  Subsequent  investigation  has  shown  that  this  cor- 
responds with  considerable  accuracy  to  the  diastolic  pressure. 
This  first  instrument  of  Marey  was  much  elaborated  by 
Hiirthle  at  a  later  date.  As  his  apparatus  is  very 
cumbersome  and  suited  only  to  laboratory  use,  it 
need  not  detain  us  here. 

b.  Marey's  Second  Instrument. — Marey,  however, 
devised  a  second,  smaller  form  (Fig.  10),  which  re- 
ceived a  single  finger  and  transmitted  the  pulsa- 
tions direct  to  the  mercury  column ;  but  the  volume 
changes  in  one  finger  proved  too  slight  to  give  sat- 


FiG.  10. — Marey's  second  sphygmomanometer. 


isfactory  readings.  It  was  discarded  until,  in  1895,  Mosso, 
using  it  as  a  basis,  constructed  his  admirable  laboratory  sphyg- 
momanometer . 

c.  Mosso's  Apparatus.^ — The  essential  parts  of  this  rather 
complicated  apparatus,  shown  in  Fig.  11,  are:  1st,  Four  metal 
tubes  (BB)  enclosing  loose  rubber  glove  fingers,  into  which  are 
thrust  the  two  middle  fingers  of  each  hand.  2d,  A  recording 
mercurial  manometer  (A)  connecting  with  the  tubes  (BB) 
through  the  tube  (D),  filled  with  water.  3d,  A  pump  (C), 
whose  piston  is  slowly  depressed  by  turning  a  crank.  The 
whole  apparatus  is  filled  with  water  from  the  bottle  (F),  the 

^  For  tracings  illustrating  this  see  Figs.  18  and  20. 

'  Mosso,  A.  Sphygmomanometre  pour  mesurer  la  pression  du  sang  chez 
I'houame.    Arch.  Ital.  de  Biol.,  1895,  vol.  xxiii,  p.  177. 


52  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

air  driven  out  through  the  cock  (E)  and  the  pressure  raised, 
either  gradually  or  by  steps  of  10  mm.  each,  until  the  tracing 
of  the  manometer  attains  its  maximum  height.  This  instru- 
ment is  only  suited  to  laboratory  use,  and  shares,  with  others 


i'lU.    11. Muwsu'tj    Sl'llVOMUAlANoMKl'iilv. 

which  determine  pressure  in  the  small  vessels  of  the  finger, 
certain  disadvantages  to  be  considered  later.  It  has  yielded 
much  accurate  information,  however,  and  suggested  the  evo- 
lution of  our  present  clinical  sphygmomanometers  which  meas- 
ure diastolic  pressure. 


DEVELOPMENT   OF   SPHYGMOMANOMETERS    53 

d.  Oliver's  Haemodynamometer.^— Oliver,  in  1898,  brought  for- 
ward a  simple  instrument  for  the  measurement  of  arterial 
pressure,  consisting  of  a  circular  spring  manometer,  graduated 
in  mm.,  Hg.,  with  a  hollow  metal  stem  terminating  at  its  foot 
in  a  small  rubber  bag  filled  with  fluid.  With  this,  compres- 
sion is  made  over  any  exposed  artery  until  the  oscillation  of 
the  needle  on  the  dial  attains  its  maximum,  which  Oliver 
thought  corresponded  to  mean  arterial  pressure.  The  instru- 
ment marks  a  return  to  the  v.  Basch  method  of  compression, 
and  therefore  is  liable  to  all  the  errors  of  faulty  application 
which  we  have  considered ;  besides,  its  manometer  is  not  trust- 
worthy unless  standardized  frequently.  It  cannot,  therefore, 
be  ranked  with  the  modern  instruments,  though  its  construc- 
tion is  simple  and  ingenious. 

e.  Hill  and  Barnard's  Pocket  Sphygmometer. ^ — This  little  in- 
strument may  fit  a  waist-coat  pocket,  but  has  scarcely  more 
value  than  the  finger  as  a  measure  of  pulse  tension.  It  con- 
sists of  a  vertical  glass  tube  six  inches  long,  ending  above  in  a 
small  bulb  with  glass  stop-cock.  Below  it  expands  into  an 
open  cup,  which  is  covered  by  a  rubber  membrane,  hke 
V.  Basch's  pelotte.  The  tube  is  filled  with  glycerine  colored  by 
chromic  acid,  and  is  graduated  empirically  in  mm,  Hg.  To 
use  it,  the  stop-cock  is  closed  and  the  tube,  held  vertically,  is 
pressed  down  on  the  artery  until  the  pulsation  becomes  max- 
imal. 

C.  Change  in  Color  of  the  Skin  as  a  Means  of  Determining 
Systolic  Pressure. — Indirectly,  Marey's  observations  suggested 
another  criterion  for  the  determination  of  sys- 
tolic pressure;  viz.  the  change  in  color  of  the 
skin.  This  was  used  at  about  the  same  period,  1875,  by 
V,  Kries,  in  measurements  of  capillary  pressure,  but  has  re- 
cently come  into  prominence  through  a  popular  sphygmoma- 
nometer which  embodies  it  as  its  principle,  the  tonometer  of 
Gartner. 

1  Oliver,  George.  A  Simple  Pulse  Pressure-Gauge.  Jour,  of  Physiol.,  1897- 
98,  vol.  xxii,  p.  51.  A  Contribution  to  the  Study  of  the  Blood  and  Blood- 
pressure,  Geo.  K.  Lewis,  London,  1901,  pp.  104  to  273. 

2  Hill,  L.,  and  Barnard,  H.  A  Simple  Pocket  Sphygmometer  for  Estima- 
ting Arterial  Pressure  in  Man.  Jour,  of  Physiol.,  1898,  vol.  xxiii.  Proceed,  of 
Physiol.  Soc,  p.  iv. 


54  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 


3.    THE    METHOD    OF    CIRCULAR    COMPRESSION 
BY  AIR   (Riva-Rocci.    Hill) 

None  of  the  sphygmonianometers  introduced  prior  to  1896 
complied  with  all  the  essential  requirements  for  general  use 
by  physicians;  reasonable  accuracy,  freedom  from  subjective 
errors,  ease  of  application,  and  portability.  The  more  exact 
instruments,  such  as  Mosso's,  were  very  cumbersome ;  the  light 
and  compact  ones  had  all  the  errors  of  the  v.  Basch  apparatus, 
and  fre(iuently  more.  This  technical  difficulty  was  first  over- 
come by  Riva-Rocci,^  and  by  Hill,"  the  former  in  an  instrument 


Fio.  12. — Cross-.section  of  arm, 
Riva-Rocci  armlet. 

R  =  inner  wall  of  rubber  tube. 

R'=outer  wall  of  rubber  tube. 

C  =  silk  cover. 

B^  clamp,  fastened  by 

S  :=  screw. 


Fio.  13. — Cross-section  of  arm, 
Hill  and  Barnard  armlet. 

R  =  inner  wall  of  ruV)ber  bag. 
R'=  outer  wall  of  rubber  bag. 
0  =leatlier  cutf. 
B  =  strap,  fastened  by  buckle. 


In  each  T  =  tube  leading  to  manometer. 
A  ^brachial  artery. 
II  ^humerus. 


for  the  measurement  of  systolic  pressure,  the  latter  for  dias- 
tolic. Though  the  former  pubHshed  first,  it  is  questionable 
whether  the  credit  of  the  new  device  does  not  belong  to  Hill. 

The  important  feature  in  both  instruments  was  the  adoption 
of  a  rubber  tube  or  bag,  encirchng  the  arm  and  inflated  by 


'  Riva-Rocci.  Un  nuovo  sfigmomanoinetro.  Gazz.  Med.  di  Torino,  1896, 
No.  50,  51. 

2  Hill,  Leonard,  and  Barnard.  Harold.  \  Simple  and  ("onipact  Form  of 
Spliyj,'ni<)niotor  or  Arterial-i)rc.ssuro  Oaugc  devised  for  Clinical  Use.  Briti.sh 
Med.  Jour.,  1897,  vol.  ii,  p.  904. 


METHOD   OF   CIRCULAR  COMPRESSION         55 

means  of  a  bulb  or  pump,  as  the  compressing  mechanism  (see 
Chapter  IV).  We  have  seen  that  the  most  serious  error  of  the 
V.  Basch  sphygmomanometer  was  due  to 
the  difficulty  of  compressing  the  radial 
artery  directly  against  the  bone  with  the 
small  and  awkward  pelotte. 

The  accompanying  cuts  (Figs.  12  and 
13)  show  the  new  method.      The    Riva-      fig.  i4.  — Ckoss-section 
Rocci  tube  completely  encircles  the  arm        of  finger  with  Gaut- 
and  fastens  with  a  special  clamp,  while        ^^^  ^^^^' 
the  armlet  of  Hill  surrounds  more  than      ^=5';"^;;  ™''''""   '"""' 
half  of  it  and  is  held  in  place  by  an  outer     c=mctai  rins. 

J    r,       1  1  T  -XT  T  =  tube    leading   to  ma- 

leather  cutt  and   buckle,     in  either  case  nometer. 

the   pressure    is    everywhere    exerted    at     p=^haknf^eai  bone.' 

right  angles  to  the  surface  of  the  arm, 

and  therefore  must  compress   the  artery  equally  from  three 

sides  against  the  underlying  bone. 

Gartner,^   in    his   tonometer,    uses   a   practically  identical 

method  of  compressing  the  finger. 


4.    EXPERIMENTAL    VERIFICATION    OF    THE 
METHOD    OF    CIRCULAR    COMPRESSION 

If  the  results  of  the  various  sphygmomanometers  using  the 
method  of  circular  compression  are  to  be  accepted  as  having  an 
absolute,  or  nearly  absolute,  value,  the  method  must  be  found 
to  comply  with  certain  fundamental  requirements. 

A.  Influence  of  the  Inner  Wall  of  the  Tube. — The  pres- 
sure exerted  upon  the  limb  must  be  exactly  the 
pressure  within  the  tube.  This  question  was  thor- 
oughly investigated  by  Gumprecht,^  who  found  a -substantial 
correspondence  between  the  internal  pressure  and  the  pressure 
exerted.  There  was  no  increasing  loss  as  the  pressure  was 
raised,  as  would  have  been  the  case  had  the  elasticity  of  the 
tube  itself  been  called  into  play. 

^  Gartner,  G-.  Ueber  einen  neiien  Blutdruckinesser  (Tonometer).  Wien. 
med.  Wochenschr.,  1899,  vol.  xlix,  p.  1412. 

-  Gumpreclit.  Experimentelle  und  klinische  Priifung  des  Riva-Rocci'scheu 
Sphygmomanometers.    Zeitschr.  f.  klin.  Med.,  1900,  vol.  xxxix,  p.  377. 


56  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

a.  Influence  of  Faulty  Adjustment. — This  only  holds  good 
when  the  armlet  is  properly  applied,  that  is,  snugly,  but  not  so 
tightly  as  to  exert  any  pressure  before  inflation,  I  have  fre- 
quently found  the  reading  as  much  as  20  mm.  to  30  mm.  too 
high,  on  account  of  loose  adjustment  of  the  cuff.  This  is  espe- 
cially prone  to  happen  in  those  instruments  in  which  the  cuff 
is  buckled  on,  one  hole  being  too  loose  and  the  next  too  tight. 
It  is  more  easily  avoided  with  the  original  Riva-Rocci  clamp, 
or  the  type  of  buckle  adopted  in  my  modification.  With  the 
compressing  finger  ring  of  the  Gartner  tonometer,  it  becomes 
much  more  difficult  to  fit  each  case,  without  carrying  a  large 
number  of  rings  of  different  sizes.  Martin,^  who  has  investi- 
gated the  point  carefully  and  gives  convincing  experimental 
evidence,  thinks  the  error  from  erroneous  application  much 
greater  than  with  the  Riva-Rocci,  and  that  the  adaptation  of 
ring  to  finger  must  be  very  exact,  even  to  differences  of  1  mm. 
in  circumference.  For  this  reason  he  has  devised  a  small  mod- 
ified Riva-Rocci  tube,  of  2.5  cm.  width,  for  the  finger,  and  ob- 
tains accurate  results  with  it.  Wolf  ^  found  a  similar  infiuence 
of  the  calibre  of  the  ring,  smaller  rings  giving  higher  readings 
on  an  artificial  rubber  finger  filled  with  mercury  and  connected 
with  a  manometer  tube.  Of  seventy-two  observations  on  the 
two  hands,  in  only  one  half  did  the  readings  correspond. 

B.  Influence  of  the  Tissues. — T he  pressure  exerted  by 
the  tube  upon  the  arm  must  either  be  transmit- 
ted without  loss  to  the  blood -column  within  the 
artery,  or  the  loss  must  be  a  constant  factor, 
capable  of  calculation.  The  earlier  investigations  on 
this  point  led  to  the  conclusion  that  there  was  a  certain 
loss,  due  to  the  compressibility  of  the  tissues,  which  was 
called  the  elasticity  error.  It  was  variously  estimated.  Gum- 
precht  placed  it  at  30  mm.  for  moderate  pressures  and  rising 
to  40  or  50  mm.  at  high  pressure;  Hensen^  at  10  to  15  mm.  in 

^  Martin,  Alfred.  Technisclics  iiber  das  Rivii-Kocci'sehe  Sphygmomano- 
meter und  Gartner's  Tonometer.  Miinch.  med.  Wochenschr.,  1903,  vol.  1,  pp. 
1021  and  1072. 

'  Wolf,  IT.  Experimentelle  Untersuchutigen  iiber  die  Blutdruckmessungen 
mit  dem  Gartner'sclion  Toiiometor.  Wion.  med.  Presse,  1902,  vol.  xliii,  pp.  1349 
and  139r>. 

'  Ilensfin,  II.  Hcitiagi;  zur  Pliysiolofijie  und  Pathologie  des  Blutdrucks- 
Deutsch.  Arch.  f.  kliii.  xMed.,  1900,  vol.  xlvii,  p.  437. 


METHOD   OF   CIRCULAR  COMPRESSION 


57 


adults,  3  mm.  in  children.  The  latter  called  attention  to  the 
important  fact  that,  were  the  error  at  all  considerable,  it 
would  be  very  noticeable  in  a  long  series  of  observations  on 
arms  of  varying  size.  It  must  increase  proportionally  to  the 
area  of  cross-section,  not  the  circumference  of  the  arm,  there- 


b        B 


Tig.  15. — Distortion  of  a  tube  by  blocks  laid  on  it. 
(From  V.  Recklinghausen,  p.  87.) 

fore  if  there  were  an  error  of  many  mm.  Hg.  in  normal  arms, 
it  should  be  impossible  to  find  moderate  pressures  in  large 
arms.  This  is  not  the  case  in  my  experience  or  that  of  other 
observers. 

a.  Relation  of  Width  of  Armlet  to  Circumference  of  Limb. 
V.  Recklinghausen. — v.  Recklinghausen,^  in  his  excellent  crit- 
ical studies,  approached  the  question  from  another  standpoint. 

He  believed  that  the  soft  parts  exerted  no  influence  what- 
ever, and  investigated  the  effect  of  the  length  of  artery  com- 

'  V.  Recklinghausen,  H.  Ueber  Blutdruckmessung  beiin  Menschen.  Arch, 
f.  exper.  Pathol,  u.  Pharmakol.,  1901,  vol.  xlvi,  p.  78. 


58  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

pressed.  The  foregoing  diagram  (Fig.  15)  shows  his  method 
of  reasoning.  It  is  evident  that  the  portions  of  tube  B  C  carry 
some  of  the  weight  B.  If  a  number  of  weights  of  the  same 
size  be  laid  along  the  tube,  not  increasing  the  pressure  to  the 
square  inch,  the  outer  blocks,  on  AB  only,  will  feel  this  pull, 
while  the  central  ones  will  exert  their  full  pressure  upon  the 
portion  of  tube  directly  beneath  them.  With  this  in  view  he 
constructed  armlets  of  different  widths,  and  found  that  a  cer- 
tain proportion  must  be  maintained  between  circumference  of 
arm  and  length  of  it  compressed.  For  ordinary  arms  of  24 
cm.  circumference,  a  10  cm.  cuff  sufficed,  and  12  to  15  cm. 
was  adequate  for  almost  any  size.  When  too  small  an  armlet 
was  used,  the  readings  were  considerably  higher  than  with  the 
proper  width.  Since  the  Riva-Rocci  arm-piece  has  a  width  of 
at  most  5  cm.  and,  when  distended,  becomes  circular  aijd  is 
in  contact  with  an  even  smaller  surface,  v.  Recklinghausen 
thought  that  he  had  discovered  the  cause  of  the  so-called  elas- 
ticity error  of  former  observers  and  its  cure.  In  this  I  believe 
he  was  fully  justified.  His  results  have  been  substantiated  re- 
cently by  Martin,  who  adopted  a  10  cm.  width,  and  Erlanger,^ 
who  has  modified  his  very  exact  apparatus  by  the  substitution 
of  a  12  cm.  cuff  for  his  previous  one.  In  experimenting  with 
dogs,  estimations  from  the  thigh,  with  cuffs  of  3.5  cm.  width, 
showed  errors  ranging  as  high  as  50  mm.  Hg. ;  but  with  9  cm. 
width  the  error,  under  normal  conditions,  was  never  greater 
than  10  mm.  Whatever  error  was  present  entered  etjually 
into  the  determination  of  systolic  pressure  (obliteration  of 
pulse),  and  diastolic  pressure  (maximum  pulsation).  In  this 
country,  besides  Erlanger,  Stanton  ^  has  introduced  an  armlet 
of  8  cm.  width  in  his  instrument,  and  the  author  one  of  12  cm. 
in  his  new  form.  With  it  I  have  found  readings,  in  high  ten- 
sion pulses,  as  much  as  GO  mm.  lower  than  with  the  5  cm. 
tube.  This  increase  of  the  error  at  high  pressures,  which 
certainly  occurs  and  which  Gumprecht  first  pointed  out,  I  be- 

'  Erlanger,  Joseph.  A  Study  of  the  Errors  involved  in  the  Determination 
of  the  Blood-pressures  in  Man,  together  with  a  Demonstration  of  the  Improve- 
ments in  the  Sphygmomunometer  suggested  thereby.  Am.  Jour,  of  Physiol., 
1904,  vol.  x;  Proceed,  of  Am.  Physiol.  Soc.,  p.  xiv. 

^Stanton,  W.  B.  A  Practical  Clinical  Mt-thod  for  determining  Blood-pres- 
sure in  Man,  with  a  Discussion  of  the  iMi-thods  Jlitherto  employed.  Univ.  of 
Penn.  Med.  Bull.,  1903,  vol.  xv,  p.  46G. 


METHOD   OF   CIRCULAR  COMPRESSION 


59 


lieve  is  due  to  the  fact  that  the  compressing  surface  grows 
smaller  the  higher  the  pressure  is  raised,  since  the  tube  be- 
comes more  circular  in  cross-section  as  it  distends. 

V.  Recklinghausen  gives  the  following  table,  which  illus- 
trates the  difference  between  the  old  size  of  compressing  sur- 
face and  that  recommended  by  him. 

SIMULTANEOUS  DETERMINATIONS  WITH  THE  5  CM.  WIDE  CUFF 

OP  RIVA-ROCCI  ON  ONE  ARM  AND  A  12  CM. 

WIDE  CUFF  ON  THE  OTHER 

Person  H.,  sitting,  directly  after  dinner.  Pressures  in  mm.  Hg.  Maxi- 
mum circumference  of  each  arm  243^  cm.  (Thiclier  arms  would  naturally  give 
greater  differences.) 


Pulse  returns 

Pulse  returns 

Pulse  disappears. 

Pulse  returns . . . . 

Pulse  returns. . . . 

Pulse  returns. . . . 

Pulse  disappears. 


BROAD   CUFF 


Right  arm. . . . 

...  90-  96 

Right  arm.  . . 

...  92-100 

Right  arm . . . . 

...  90-  98 

Right  arm . . . 

...  92-  98 

Left  arm .... 

...  96-104 

Left  arm 

...  94-104 

Left  arm 

. . . 104-108 

Average 94-101 


RIVA-ROCCI  S  CUFF 


Left  arm 116 

Left  arm 114 

Left  arm 112 

Left  arm 114 

Right  arm 118 

Right  arm 120 

Right  arm 120 

.....116 


With  the  lower  pressure  values  of  the  first  column  the  mercury  manometer 
showed  marked  pulsations,  with  the  higher  ones  of  the  second  column  it  stood 
quite  still.    (After  v.  Recklinghausen,  loc.  cit.,  p.  110.) 

With  the  finger  ring  of  the  Gartner  tonometer  he  found  a 
similar  influence  of  the  extent  of  compressing  surface,  and 
recommends  a  ring  covering  the  whole  proximal  phalanx. 
Martin  does  not  wholly  agree  in  this,  finding  2.5  cm.  suffi- 
cient, instead  of  the  1.5  cm.  width  of  the  original  Gartner 
ring. 

b.  Influence  of  the  Site  of  Application. — In  all  blood-pressure 
determinations,  whether  by  direct  or  indirect  methods,  it  is 
essential  that  the  measurement  be  taken  at  the  level  of  the 
heart.  The  reason  for  this  is  simple.  If  the  observation  be 
made  at  a  point,  let  us  say,  10  cm.  lower  than  the  heart,  we 
shall  measure  not  only  the  blood-pressure,  but  the  weight  of  a 
column  of  blood  10  cm.  high  in  addition.  This  equals  about 
8,5  mm.  of  mercury.  If  the  point  be  above,  a  corresponding 
error  will  be  introduced  in  the  negative  direction. 


60  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

With  the  12  cm.  cuff  it  is,  of  course,  immaterial  on  what 
segment  of  the  hmb  it  be  placed,  so  long  as  it  can  be  adapted 
smoothly  to  it.  Determinations  may  be  made  equally  on 
arm  or  thigh,  or  even  on  the  calf.  In  children,  whose  arms 
are  very  small,  the  thigh  is  to  be  preferred.  This  obviously 
necessitates  the  recumbent  posture  to  keep  the  level  of  the 
heart. 

The  Gartner  method  of  finger  compression  is  not  so  fortu- 
nate in  this  respect.  Martin  found  that  the  ring  must  be 
placed  exactly  on  the  middle  phalanx,  as  Gartner  originally 
directed,  under  penalty  of  a  possible  error  of  10  mm.  or  more. 
He  explains  the  results  of  many  of  the  critics  of  the  tonom- 


A  Fig.  16.  B 

A.  Manner  of  closure,  normal  artery. 

B.  Manner  of  closure,  sclerotic  artery,  leaving  open  corners. 

(After  V.  Eecklingliausen,  p.  104.) 

eter,  who  have  found  marked  variation  in  simultaneous  read- 
ings from  different  fingers,  as  due  to  this  technical  error. 

c.  Influence  of  the  Vessel  Wall. — Since  the  experiments  of  v. 
Basch  already  quoted  (see  page  49)  showed  that  a  pressure  of 
1  mm.  was  always  sufficient  to  close  the  lumen  of  an  excised 
radial  artery,  the  error  from  this  source  may  be  absolutely 
neglected.  That  a  sclerotic  vessel  may  offer  considerable 
resistance  to  compression  is,  however,  a  common  belief,  which 
I  do  not  think  is  justified,  v.  Basch  found  the  empty  sclerotic 
radial  could  be  compressed  by  5  mm.  Hg.  The  digital  arteries 
should  give  an  even  lower  figure,  but  that  the  larger  brachial 
would  offer  more  resistance  seems  plausible.  Hensen,^  from  an 
observation  on  a  dying  consumptive  with  moderate  arterio- 
sclerosis of  the  brachial,  in  whom  he  found  a  blood-pressure  of 
30  to  40  mm.,  argued  that,  since  there  was  still  some  internal 
pressure  in  the  vessel,  the  error  due  to  rigidity  of  its  walls 
could  not  have  exceeded  20  mm.  I  am  inclined  to  doubt  the 
accuracy  of  touch  which  can  detect  a  pulse  of  such  small  vol- 

*  Hensen.    lioc.  cit.,  p.  505. 


METHOD   OF   CIRCULAR  COMPRESSION  Gl 

ume  as  a  systolic  pressure  of  10  to  20  mm.  would  imply,  and, 
were  the  return  of  the  pulse  really  palpable,  should  consider 
the  overestimation  to  have  been  less  than  10  mm.  v.  Reck- 
linghausen ^  thinks  it  more  probable  that,  with  marked  thicken- 
ing of  the  artery,  its  walls  do  not  collapse  in  the  same  manner 
as  the  normal  ones,  when  the  internal  pressure  has  been  equal- 
ized, but  leave  a  small  opening  at  each  side  through  which  a 
rudimentary  pulse-wave  might  pass  (see  Fig.  IG).  In  such 
cases  he  suggests  leaving  these  rudimentary  waves  out  of  con- 
sideration and  using  the  first  well-developed  pulse  as  the  cri- 
terion.    In  this  I  am  inclined  to  agree  with  him. 

The  problem  will  be  discussed  again  later,  in  considering 
the  complicated  relation  of  arterio-sclerosis  to  blood-pressure; 
but  my  personal  belief,  based  on  a  number  of  cases  of  marked 
thickening  or  calcification  of  the  large  arteries,  in  which  I 
have  failed  to  find  abnormally  high  systolic  pressures,  is,  that 
errors  from  this  source,  with  the  wide  armlet,  and  using  the  first 
fully  formed  pulse  as  a  guide,  have  little  significance. 

d.  Influence  of  Muscular  Contraction. — In  connection  with  this 
loss  of  pressure  in  transmission  through  the  tissues,  there  are 
certain  avoidable  sources  of  error.  Muscular  relaxation  on  the 
part  of  the  subject  must  be  complete.  Hensen^  found  the 
same  pressure  on  the  two  sides  in  fresh  hemiplegics  with  flac- 
cidity ;  showing  that  normal  muscle  tonus  during  relaxation  is 
without  influence.  Muscular  contraction,  however,  at  once  intro- 
duces an  obstacle  to  the  compression  of  the  artery,  which  the 
same  observer  proved  might  cause  an  overestimate  of  5  mm.  to 
80  mm.,  depending  upon  the  force  used.  This  renders  accurate 
observations  impossible  in  spastic  conditions,  tetanus,  marked 
subsultus,  and  all  states  of  heightened  muscular  tone. 

e.  Influence  of  (Edema. — (Edema  is  a  similar  source  of  error, 
for  some  of  the  pressure  is  expended  in  squeezing  the  fluid  out 
of  the  tissues,  so  that  the  tube  gradually  produces  a  groove  in 
the  limb.  Hensen  found  the  reading,  in  an  arm  with  slight 
oedema,  20  mm.  higher  than  in  the  opposite  one.  It  is  wiser 
not  to  attempt  determinations  when  it  is  present.  On  the  same 
ground,  a  change  in  the  normal  elasticity  of  the  tissues,  the  ex- 

^  V.  Recklinghausen.     Loc.  cit.,  p.  104. 

^  Hensen,  H.  Beitrage  zur  Physiologie  unci  Pathologie  des  Blutdrucks. 
Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol.  xlvii,  p.  437. 


62  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

perimental  verifications  of  sphygmomanometers  on  the  cadaver 
cannot  be  accepted. 

C.  Conclusions. — As  a  result  of  the  critical  investigations  we 
have  considered,  the  essential  accurac}^  of  the  method  of  circular 
compression  has  been  demonstrated.  The  use  of  an  armlet  of 
12  cm.  width,  adjusted,  with  reasonable  care  as  to  tightness, 
anywhere  upon  the  arm  or  thigh,  enables  us  to  exert  upon  the 
main  artery  of  the  limb  a  pressure  nearly  or  quite  equal  to 
that  within  the  armlet.  The  maximum  error  by  this  method 
is  10  mm.  Hg.,  due  to  loss  in  transmission  through  the  tissues. 

The  method,  as  applied  to  the  finger  (Gartner  tonometer),  re- 
quires more  care  in  the  accurate  fitting  of  the  ring  to  the  middle 
phalanx,  and  seems  to  give  less  constant  results,  but  is  still  of 
sufficient  reliabihty  for  clinical  purposes.  Since  the  pressure 
within  the  ring,  or  armpiece,  can  be  exactly"  measured  by  a 
manometer,  the  technical  requirements  for  accurate  clinical 
measurements  of  blood-pressure  have  been  fulfilled.  It  re- 
mains only  to  prove  that  our  external  indicators  of  the  equali- 
zation of  certain  definite  pressures  within  the  artery,  systolic 
and  diastolic,  correspond  with  the  event. 

5.  THE  VALIDITY  OF  THE  SEVERAL  CRITERIA 

A.  Of  Systolic  Pressure. — a.  The  Return  of  the  Pulse-Wave 
Under  Compression. — This,  we  have  seen,  was  the  original  crite- 
rion of  Vierordt  and  v.  Basch.  Formerly  it  was  questioned 
whether  the  moment  of  disappearance  or  of  reappearance  should 
be  used.  There  is  no  doubt,  however,  that  the  moment  of  re- 
turn is  more  sharply  defined  and  more  easily  detected,  and  it 
is  now  the  generally  accepted  standard. 

If,  during  the  gradual  release  of  the  pressure  on  the  arm, 
tracings  be  taken  from  the  radial  artery  with  a  sphj^gmograph, 
as  in  my  earlier  work  on  this  subject  ^  and  Masing's,^  or,  like 
V.  Recklinghausen,^  a  volume  trace  made  from  the  forearm,  the 

1  Janeway,  Tlieodore  C.  Some  Observations  on  the  Estimation  of  Blood- 
pressure  in  Man,  with  Especial  Reference  to  the  Results  obtained  with  the  Newer 
Sphygmomanometers.     N.  Y.  Univ.  Bull,  of  the  Med.  Sci.,  1901,  vol.  i,  p.  105. 

2  Masing,  Ernst.  Ueber  das  Verhaltcn  des  Blutdrucks  des  jungen  und  des 
bejahrten  Menschen  boi  Muskelarbeit.  Doutsch.  Arch.  f.  klin.  Med.,  1902,  vol. 
Ixxiv,  p.  253. 

3  Loc.  cit.,  p.  103. 


THE   VALIDITY   OF   THE   SEVERAL   CRITERIA  03 

first  few  waves  to  reappear  will  be  barely  visible;  then,  after 
only  a  few  mm.  fall  in  the  pressure,  larger  pulse-waves  will 
suddenly  show,  as  is  readily  seen  in  Fig.  17.  The  last  writer 
calls  the  small  waves  rudimentary,  the  later  large  ones,  well- 
developed.  The  detection  of  the  rudimentary  waves  requires 
skill  and  care,  as  well  as  a  favorably  placed  artery.  Hensen 
thinks  it  easier  to  detect  them  at  the  bend  of  the  elbow,  but  I 


Fig.   17. — Tracings  from  the  forearm  by  Erlanger's  sphygmomanometer  during 
the  release  of  pressure  in  another  instrument  on  the  upper  arm. 

A.  Slow  release.     Rudimentary  waves  at  102  mm.,  well-developed  at  98  mm.    The 

pulse,  at  102  mm.,  was  palpable,  with  care. 

B.  Fast  release.     Rudimentary  waves  at  100  nmi.,  well-developed  at  about  90  mm.     A 

few   abnormally  large   pulses   came  through  above   100  mm.     The   pulse   could 
scarcely  have  been  felt  above  95  mm. 

have  found  this  an  awkward  procedure,  and  even  more  unsatis- 
factory in  stout  arms  than  palpation  at  the  wrist.  E\'idently, 
therefore,  in  some  cases  the  well-developed  waves  are  the  first 
felt,  and  with  the  novice  this  is  the  rule.  The  underestima- 
tion I  do  not  believe  can  exceed  5  mm. ,  where  due  care  is  used, 
except  with  irregular  or  very  rapid  pulses,  since  the  points  of 
disappearance  and  return  may  usually  be  determined  within  5 
mm.  of  one  another.     Cook  and  Briggs,^  who  take  the  mean 


^  Cook,  H.  W.,  and  Briggs,  J.  B.    Clinical  Observations  on  Blood-pressure. 
Johns  Hopkins  Hosp.  Rep.,  1903,  vol.  xi,  p.  451. 


64  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

of  these  two  points,  do  not  consider  readings  satisfactory  that 
differ  by  more  than  2  or  3  mm. 

One  technical  point  must  be  insisted  on.  The  pressure  must 
be  lowered  very  gradually,  for,  not  only  the  rudimentary 
pulses,  but  several  subsequent  ones  will  be  missed,  if  the  mer- 
cury be  allowed  to  fall  5  or  10  mm.  at  a  time.  (See  Fig.  17.) 
It  is  always  wise,  so  soon  as  the  return  of  the  pulse  is  per- 
ceived, quickly  to  raise  the  pressure  the  few  mm.  Hg.  neces- 
sary to  again  obliterate  it  and  make  a  second  determination, 
taking  the  average  of  the  two.  For  this  purpose  the  instru- 
ments in  which  pressure  may  be  rapidly  changed  in  either 
direction  with  one  hand  (v.  Recklinghausen,  Erlanger,  Stan- 
ton, Jane  way)  have  a  great  advantage. 

To  obviate  the  subjective  element  in  the  determination, 
Erlanger  has  proposed  a  method  of  rendering  the  return  of  the 
pulse  visible,  which  he  calls  ' '  letting  the  cuff  feel  the  return 
of  the  pulsation."  Having  raised  the  pressure  in  the  sphyg- 
momanometer considerably  higher  than  maximum  arterial 
pressure,  he  brings  the  recording  lever  of  the  tambour,  in  his 
instrument,  to  bear  on  the  drum.  The  lever  is  depressed  and 
shows  a  small  pulse.  The  pressure  is  then  allowed  to  fall 
gradually  and  the  pulsations  increase  slightly,  while  the  lever 
rises.  At  the  instant  the  pressure  in  the  armlet  falls  below  the 
systolic  pressure  in  the  artery,  the  pulsation  shows  an  abrupt 
increase  in  amplitude  (see  Fig.  20).  This  method,  he  has  sat- 
isfied himself,  is  both  accurate  and  objective.  He  claims  that 
the  readings  so  obtained  are  5-15  mm.  higher  than  when 
the  finger  is  used  to  detect  the  return  of  the  pulse.  This  may 
hold  good  when  the  fully-developed  pulse  is  considered,  but, 
with  slow  release  of  pressure  and  a  little  skill,  the  rudimentary 
waves  may  be  felt,  and  I  have  never  found  my  readings  more 
than  2-5  mm.  below  simultaneous  ones  by  his  method.  An 
objection  to  his  method,  for  routine  clinical  use,  is  that  it  con- 
sumes more  time,  and  requires  quite  as  much  skill.  In  patho- 
logical pulses,  the  change  may  be  very  indistinct.  It  is,  of 
course,  only  applicable  with  a  graphic  instrument. 

Apart  from  the  adequacy  of  the  sense  of  touch  to  detect 
these  slighter  waves,  however,  we  must  question  whether  the 
pulse  passes  through  the  compressed  portion  of  the  vessel  the 
instant  the  pressure  without  falls  below  that  within  the  artery. 


THE  VALIDITY   OF   THE   SEVERAL   CRITERIA  65 

With  the  broad  armlets  there  must  be  8  or  10  cm.  of  artery 
collapsed,  and  the  first  pulse- waves  might  lose  their  small  in- 
itial surplus  of  pressure  in  overcoming  friction,  before  reach- 
ing the  wrist  or  even  the  elbow.  This  v,  Recklinghausen 
showed  was  undoubtedly  the  case.  By  his  very  ingenious 
method  of  "  Staircase  curves,"  he  was  able  to  measure  the  ab- 
solute systolic  pressure,  and,  in  one  curve  which  he  figures, 
the  first  developed  pulse  he  could  detect  came  through  at  a 
pressure  6  mm.  Hg.  (8  cm.  water)  lower.  This  difference  he 
calls  the  extra  pressure  required  to  open  the  path.  Some  con- 
sider the  existence  of  this  cause  of  low  measurements  good 
reason  for  using  the  average  of  the  pressures  found  at  the  mo- 
ment of  disappearance  and  of  reappearance  of  the  pulse,  the 
former  being  invariably  higher;  nevertheless,  the  disappear- 
ance is  so  much  more  gradual  and  misleading  than  the  return, 
that  most  observers  agree  in  preferring  the  definite  end  reaction 
with  a  small,  fairly  constant  error.  It  may  further  be  urged, 
that  the  probable  underestimation  of  5  mm.  +  6  mm.  =11  mm. 
in  the  criterion  used,  may  serve  to  cancel  the  equally  probable 
overestimate  of  10  mm.,  due  to  the  resistance  of  the  tissues 
and  the  arterial  wall.  This  reasoning  is  certainly  not  sound 
where  absolute  values  are  essential,  yet  the  variations  in  blood- 
pressure  from  slight  causes  during  the  course  of  an  observa- 
tion are  of  such  extent,  that  this  error  of  observation  is  imma- 
terial. A  change  of  5  mm,  or  even  10  mm.  in  blood-pressure, 
unless  all  the  conditions  are  absolutely  safeguarded,  affords  no 
basis  for  deduction,  and  could  only  be  allowed  weight  where 
the  observations  followed  one  another  very  closely.  In  that 
case  the  error  would  be  absolutely  constant  and  therefore  neg- 
ligible. 

In  connection  with  the  measurement  of  the  pressure  varia- 
tion of  the  pulse-wave,  where  this  criterion  is  used  for  systolic 
pressure  and  the  principle  of  maximum  oscillation  for  diastolic, 
it  may  be  urged  that  the  latter  measures  lateral  arterial  pres- 
sure, while  the  method  we  are  considering  gives  end  pressure 
(see  page  45).  This  is  true,  but  of  no  practical  importance. 
The  figures  of  Tigerstedt^  show  that  not  more  than  yfo"  of 
the  work  of  the  heart  is  expended  in  imparting  to  the  blood- 
stream its  velocity,  the  entire  remainder  being  required  to 
'  Tigerstedt,  Lehrbuch,  p.  153. 


GG  INBmECT  MEASUREMENT  OF  BLOOD-PRESSURE 

overcome  aortic  pressure.  Hence,  at  a  pressure  of  IGO  mm. 
Hg.,  the  difference  between  lateral  and  end  pressure  would 
only  amount  to  1  mm. 

A  final  point  remains  to  be  mentioned,  namely,  the  well- 
recognized  effect  of  compression  of  a  limb  in  raising  blood- 
pressure.  This  rise  is  general,  since  it  is  found  as  well  in  the 
opposite  arm,  and  is  unquestionably  due  to  a  central  vaso- 
motor reflex,  increasing  peripheral  resistance.  It  may  appear 
within  one  minute  as  a  rise  of  perhaps  5  mm.,  and,  if  compres- 
sion is  long  maintained,  can  cause  a  rise  of  20  mm.  Hg.  in 
exceptional  cases.  It  must  be  carefully  avoided,  by  working 
quickly  and  allowing  an  interval  to  elapse  between  every  few 
determinations.  It  will  be  more  troublesome  in  the  estimation 
of  diastolic  than  of  systolic  pressure,  since  the  latter  may  be 
easily  determined  within  half  a  minute. 

In  conclusion,  one  great  advantage  of  this  criterion  must 
be  considered.  Measuring  with  fair  exactness  the  systolic  end 
pressure  in  the  brachial  artery,  it  gives  us  the  systolic  lateral 
pressure  within  the  subclavian,  since  brachial  and  axillary  are 
continuous  in  direction,  and  therefore  a  near  approximation  to 
systolic  lateral  pressure  in  the  aorta.  This,  combined  with 
estimation  of  diastolic  lateral  pressure  in  the  brachial,  which  is 
practically  the  same  as  aortic  diastolic  pressure  (see  page  31), 
gives  the  best  insight  into  actual  variations  of  systemic  blood- 
pressure. 

b.  The  Return  of  Color  to  the  Skin  of  the  Blanched  Finger.-  - 
This  very  ingenious  method  of  making  the  moment  of  return 
of  the  pulse  visible,  though  derived  originally  from  Marey's 
observations,  in  its  practical  application  we  owe  to  Gartner. 
As  yet  it  is  used  by  his  instrument  alone.  His  original 
statement  was,  that  one  obtained  in  this  way  the  mean  blood- 
pressure,  basing  his  belief  on  comparison  of  readings  thus 
inade  in  a  dog's  tail,  with  direct  measurements  of  its  mean 
carotid  pressure.^  Such  correspondence  was,  of  course,  purely 
accidental,  since  the  method  is  theoretically  identical  with  the 
detection  of  the  return  of  the  pulse  after  compression  of  the 
arm.  The  pneumatic  ring  is  first  placed  on  the  middle  phalanx, 
the  finger  is  then  rendered  bloodless  and  the  pressure  in  the 
manometer  and  ring  raised  to  a  point  above  systolic  blood- 
»  Giirtncr,  G.     Wicn.  iiiod,  Wochciwjclir.,  1899,  vol.  xlix,  p.  1412. 


THE  VALIDITY   OF   THE   SEVERAL   CRITERIA   67 

pressure.  It  is  then  allowed  to  fall  gradually  until  the  white 
finger-end  suddenly  flushes.  In  many  cases,  if  the  pressure  be 
released  sufficiently  slowly,  a  deeper  flush  appears  a  few  mm. 
Hg.  lower.  With  the  flush,  a  throb,  synchronous  with  the 
heart-beat,  is  felt  by  the  patient.  This  second  flush  corresponds 
to  the  first  well-developed  pulse  of  the  Riva-Rocci  method. 

Gartner  claimed  for  this  criterion  that  it  gave  the  subjective 
part  in  blood-pressure  determinations  to  our  most  accurate  sense, 
sight,  while  the  Riva-Rocci  method  depended  upon  our  rather 
fallible  touch  perceptions.  The  truth  of  this  is  unquestioned, 
except  under  certain  conditions.  By  artificial  light,  and  in  the 
skin  of  the  negro,  or  the  very  anaemic,  color  judgments  are  very 
difficult.  Besides,  many  observers^  agree  that  the  flush  fre- 
quently occurs  so  gradually  as  to  be  valueless  as  a  guide. 
Hayaski  takes  the  subjective  throb  as  his  index ;  in  other  words, 
he  allows  the  patient  to  feel  the  return  of  his  own  pulse,  and 
Gartner  himself  speaks  of  the  usefulness  of  the  procedure. 
This  is  even  more  subjective  than  the  palpation  of  the  pulse  by 
the  observer,  and  requires  co-operation  on  the  part  of  the  pa- 
tient only  possible  in  the  intelligent  and  completely  conscious. 
Martin  finds  the  pressure  corresponding  to  the  throb  in  the 
highest  degree  dependent  on  the  rapidity  with  which  the  pres- 
sure is  lowered,  as  is  the  case  with  the  flush.  Both  vary  also 
with  the  amount  of  vaso-constriction  of  the  arterj?-,  nice  deter- 
minations being  possible  only  with  wide  vessels.  Martin,  in 
observations  on  himself  under  different  conditions,  found  dif- 
ferences of  5  to  19  mm.  between  the  first  and  second  flush,  and 
quotes  Schleiseik  as  placing  the  usual  difference  at  15  mm., 
Neu  at  5  to  20  mm.  in  normal  cases,  and  up  to  45  mm.  in  path- 
ological ones.  These  figures  mean  that,  with  too  rapid  lower- 
ing of  the  pressure,  an  underestimation  of  that  extent  would 
occur.  Most  observers  also  agree  that,  in  a  series  of  consecu- 
tive determinations  by  this  method  the  later  readings  are  in- 
variably higher,  to  a  greater  degree  than  occurs  with  the  Riva- 
Rocci  method,  and  therefore  not  due  wholly  to  a  real  reflex  rise 
in  aortic  pressure.  Stanton  frequently  found  a  variation  of 
30  mm.  between  the  highest  and  lowest  of  a  series  of  ten  suc- 
cessive tests  on  the  same  patient.    This  is  most  easily  explained 

*  V.  Recklingliausen,  Martin,  Stanton,  Cook  and  Briggs,  Hayaski,  etc.  Loc. 
cit. 


68  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

by  the  development  of  a  vaso-motor  paresis  in  the  finger,  caused 
by  continued  compression. 

In  conditions  of  very  low  pressure  the  criterion  fails  entirely, 
and  Gartner  himself  attempts  no  measurements  below  70  mm. 
During  ansestliesia,  also,  and  in  toxic  states,  the  method  is  diffi- 
cult of  application,  and  the  observation  of  return  of  color  is 
more  inconvenient  than  the  palpation  of  the  pulse.  Cook  and 
Briggs  gave  up  the  use  of  the  tonometer  in  part  on  this  account. 

The  most  serious  fault  of  the  criterion,  however,  lies  in  the 
fact  that,  at  the  best,  it  can  only  measure  pressure  in  the  small 
digital  arteries.  The  extent  to  which  these  are  subject  to  vaso- 
motor changes  is  notorious,  and  in  this  way  variations  in  pres- 
sure within  them  may  occur  as  a  purely  local  manifestation. 
Cold  affects  them  markedly,  and  all  who  work  either  with  the 
Gartner  or  the  Mosso  instruments  lay  special  stress  on  the 
necessity  for  having  the  fingers  warm.  Brush  and  Fayer- 
weather  *  found  these  peripheral  changes  so  troublesome,  with 
the  latter  instrument,  that  they  modified  it  for  use  on  the  wrists. 
Wolf,  in  the  series  of  seventy-two  observations  previously 
quoted,  found  differences  between  the  readings  in  the  two 
hands  in  one  half  the  cases,  the  greatest  being  25  mm.  Hg. 
Such  variation  can  only  be  due  to  defect  in  the  method,  or  to 
local  changes  in  the  calibre  of  the  digital  arteries.  Jellinek's  ^ 
figures  on  the  effects  of  exercise  in  a  large  number  of  healthy 
soldiers  seem  to  me  to  illustrate  this  fault  of  the  Gartner 
method.  Most  of  the  men  showed  a  rise  in  pressure,  some  no 
change,  and  a  few  a  fall.  One  relation,  however,  was  con- 
stant. Those  with  very  low  initial  pressures  always  showed 
the  most  marked  rise.  Since  we  know  how  exercise  tends  to 
dilate  the  vessels  of  the  skin,  the  explanation  of  his  results,  to 
my  mind,  is  found  in  the  probable  marked  vaso-constriction  of 
the  peripheral  vessels  which  existed  in  his  cases  with  low  pri- 
mary readings;  this  disappearing  under,  exercise  would  allow 
the  factitious  original  pressure  to  rise  to  the  level  of  general 
blood-pressure. 

1  Brush,  C.  E.,  and  Fayerweather,  R.  Observations  on  the  Changes  in 
Blood-pressure  during  Normal  Sleep.  Am.  Jour,  of  Physiol.,  1901,  vol.  v, 
p.  199. 

*  Jellinek,  S.  Ueber  den  lilutdruck  des  gesunden  Menschen.  Zeitsehr.  f. 
kiln.  Med.,  1900,  vol.  xxxix,  p.  457. 


THE  VALIDITY  OF   THE   SEVERAL   CRITERIA   09 

The  use  of  this  method  of  determining  systohc  pressure, 
then,  has  not  the  general  appHcjibihty  oi  those  using  the  arm, 
nor  have  its  results  quite  the  same  worth.  Within  these  limi- 
tations it  is  of  clinical  value,  is  easily  learned  and,  under 
favorable  conditions,  gives  a  beautifully  distinct  index  of  pres- 
sure, which  lends  it  a  certain  charm. 

c.  Comparison  of  Systolic  Pressures  in  Brachial  and  Digital 
Arteries. — Apart  from  local  differences  in  vascular  tone,  the 
digital  arteries  undoubtedly  have  a  slightly  lower  systolic  pres- 
sure than  the  brachial,  for  the  pulse  wave  in  them  is  smaller. 
Most  comparisons  in  the  past  have  been  with  the  Riva-Rocci 
instrument,  using  the  narrow  armlet,  therefore  with  an  over- 
estimated brachial  pressure.  Hayaski,  for  instance,  comparing 
the  moment  of  disappearance  of  the  radial  pulse  on  one  side, 
and  the  subjective  throb  on  the  other,  found  a  fairly  constant 
difference  of  20  mm.  in  a  large  number  of  cases.  As  his  nor- 
mal persons  were  one  hundred  and  eight  school  children,  the 
elasticity  error  must  have  been  smaU.  v.  Recklinghausen 
obtained  an  average  reading  from  the  finger  7  mm.  Hg.  lower 
than  for  the  brachial. 

B.  Of  Diastolic  Pressure. — a.  Maximum  Pulsation  of  the  Arte- 
rial Wall. — This  means  of  determining  the  diastolic  pressure 
within  an  artery,  which  we  owe  to  Marey's  keen  insight,  is 
unquestionably  our  most  exact  indirect  measure  of  a  blood- 
pressure.  Mosso,  when  he  first  devised  his  sphygmomanom- 
eter, demonstrated  its  theoretical  accuracy  by  the  following 
experiment.  Two  vessels  were  taken,  which  communicated 
with  one  another  by  a  vertical  opening  40  mm.  in  diameter, 
closed  by  an  unstretched  elastic  membrane.  One  vessel  was 
connected  with  the  pressure  cylinder  and  recording  manometer 
of  his  sphygmomanometer,  the  other  with  a  mercury  manom- 
eter, and  with  a  pump  used  to  imitate  the  heart  in  a  model  of 
the  circulation.  At  the  start  of  the  experiment  the  pressure 
registered  76  mm.  Hg.  in  each  vessel.  The  membrane,  there- 
fore, was  perfectly  vertical.  If  the  pressure  was  raised  on  either 
side,  it  was,  of  course,  bulged  out  toward  the  opposite  vessel. 
ISTow,  while  increasing  the  pressure  on  the  side  of  the  sphygmo- 
manometer by  successive  steps,  he  produced  plusation  of  the 
water  in  the  other  vessel,  which  was  transmitted  through  the 
membrane  to  his  recording  manometer.     The  tracing  shown  in 


70  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 


Fig.  18  resulted.  It  is  perfectly  evident  that  the  greatest  pul- 
sation is  at  76  mm.,  the  level  of  equal  pressure  on  the  two  sides 
of  the  membrane. 

Howell  and  Brush  ^  have  verified  the  principle  for  the  artery 
itself.    They  used  an  apparatus  devised  by  Walden,  and  shown 


Fio.  18. — Tracing  of  the  pulsations  transmitted  through  an  elastic  membrane 

SEPARATING    TWO    VESSELS. 

(From  Mosso,  Arch.  Ital.  de  Biol.,  1895,  vol.  xxiii,  p.  177.) 

in  Fig.  19.  The  tube  D  was  connected  with  a  mercury  ma- 
nometer and  with  a  Fick  spring  manometer,  the  latter  magni- 
fying and  recording  the  pulsations.  This  is  the  general  arrange- 
ment of  Erlanger's  sphygmomanometer.  The  left  carotid  of  a 
dog  was  placed  in  this  apparatus,  and  the  right  connected  with 
a  mercury  manometer  provided  with  maximum  and  minimum 
valves.  The  pressure  in  the  closed  cylinder  was  then  raised 
10  mm.  at  a  time,  and  the  pulsations  at  each  pressure  recorded 
by  the  Fick  manometer.  No  difficulty  was  met  in  determining 
the  greatest  amplitude  of  the  pulse-wave.  The  only  source  of 
error  lay  in  the  10  mm.  intervening  between  the  readings, 
which  made  it  possible  that  still  larger  waves  might  have 
occurred  at  some  intermediate  point.    The  error  from  this  could 

*  Howell,  W.  11.,  and  Brush,  C.  E.,  Jr.  A  Critical  Note  upon  Clinical  Meth- 
ods of  Measuring  Blood-pressure.  Boston  Med.  and  Surg.  Jour.,  1901,  vol. 
cxlv,  p.  146. 


THE  VALIDITY  OF   THE   SEVERAL   CRITERIA   71 

not  have  exceeded  5  mm.     Their  results  are  shown  in  tabular 
form. 


Experiment  VII. . . 
Experiment  VIII . . 
Experiment  IX 


Observa- 
tion. 


Diastolic  pressure  in  right 
carotid  measured  by  the 
minimum  manometer. 


156.5  mm,  Ilg. 
15G 

111 
129 

82 

93.4  " 

106 
110.5  " 


Point  at  which  the  maxi- 
mum pulsations  were 
obtained  in  the  left  caro- 
tid as  measured  by  tlie 
sphygmomanometer. 


155      mm.  Hg. 

157 

112.5    " 
129  5     " 

81 


109 
110 


*  Animal  bled  profusely. 

The  measurements  were  practically  simultaneous  and  under 
even  conditions  of  anaesthesia,  so  that  the  pressure  remained 
constant    for   considerable    intervals.      These    figures,    when 


Fig.  19. — Apparatus  of  Walden  for  verifying  the  criterion  of  maximum 

PULSATION    of   tub    ARTERIAL   WALL. 

A  A' =  artery,  tied,  cut,  and  drawn  througli  apparatus. 
BB'^ymall  glass  tubes  inserted  through  stopper  in  larger  tube. 

C^tube  of  perit<jneal  membrane  connecting  the  ends  of  BB'. 

D^  opening  from  outer  tube  leading  to  recording  apparatus  and  manometer. 

E^  opening  connected  with  pressure  flask. 

(From  Howell  and  Brush.) 

coupled  with  Mosso's  simpler  demonstration,  are  convincing 
as  to  the  essential  accuracy  of  the  point  of  maximum  ampli- 
tude of  pulsation  as  a  guide  to  diastolic  arterial  pressure. 
Certain  practical  aspects  of  it  alone  remain  to  be  touched  on 
here. 


72  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

When  used  clinically,  it  is  not  possible  to  obtain  thoroughly 
accurate  judgments  of  where  the  pulsation  is  greatest,  by  simply 
watching  the  fluctuations  of  the  mercury  column.  With  a 
manometer  of  at  least  3  mm.  calibre,  and  rigid  connecting 
tubing,  quite  large  oscillations  may  be  obtained,  and  a  reason- 
able approximation  of  diastolic  pressure  made  with  a  simple 
clinical  instrument.  With  rapid  pulses,  neither  the  eye  nor 
the  mercury  follow  the  movements  quickly  enough,  and  some 
form  of  tambour  becomes  necessary  for  magnifying  and  record- 


Fio.  20. — Tracing  from  a  normal  pulse  by  Erlangeb's  spiiygmomanometer. 

At  115  mm.  is  seen  the  abrupt  increase  in  amplitude  which  indicates  systolic  (max.) 
pressure.  At  90  mm.  the  pulsation  is  still  ma.xirnal,  but  at  85  mm.  it  is  much 
diminished.     90  mm.  is  therefore  the  diastolic  (niin.)  pressure. 

ing  them.  For  this  reason  the  types  of  apparatus  which  give 
diastolic  pressure  satisfactorily  in  all  cases  are  more  bulky, 
require  longer  for  a  reading,  and  are  more  costly,  than  the  sim- 
pler ones  measuring  systohc  pressure.  Hill  and  Barnard's  is 
an  exception  as  regards  the  first  two  drawbacks ;  but  its  deli- 
cate metal  tambour  is  easily  disordered,  and  does  not  give  exact 
readings  unless  frequently  corrected  by  comparison  with  a  mer- 
cury manometer.  Besides,  it  is  not  a  recording  manometer, 
and  sometimes  gives  one  trouble  in  determining  the  maximum 
of  the  oscillations.  It  must  also  be  borne  in  mind  that  the 
pulsations,  when  once  they  have  attained  their  maximum  with 
increasing  pressure,  remain  at  much  the  same  height  for  a 
number  of  millimeters,  then  decline  rather  suddenly  as  systolic 
pressure  is  approached.  Hill,  who  thought  his  method  indi- 
cated mean  arterial  pressure,  advised  taking  the  middle  point 
between  the  limits  of  maximal  pulsation.  This  may  at  times 
correspond  with  mean  pressure,  but  is  not  at  all  an  exact  guide. 


THE  VALIDITY  OF   THE   SEVERAL   CRITERIA   73 

The  correct  manner  of  using  the  criterion,  to  whatever  instru- 
ment it  be  applied,  is  to  lower  slowly  the  pressure  from  the 
systolic  level,  if  possible  only  5  mm.  at  a  time,  watching  the 
size  of  the  pulsations.  The  lowest  pressure  at  which  they  are 
still  of  maximal  height  is  the  diastolic  pressure.  Below  this 
they  decrease  very  rapidly  in  amplitude,  so  that  the  determi- 
nation seldom  offers  special  difficulty  with  a  graphic  record. 
The  accompanying  tracing  (Fig.  20),  taken  with  the  Erlanger 
sphygmomanometer,  illustrates  the  method.  With  irregular 
pulses  and  when  rapid  fluctuations  of  pressure  are  present,  as 
in  forced  breathing,  the  criterion  fails. 

C.  Other  Criteria,  not  in  Clinical  Use. — Hiirthle  *  rendered  the 
arm  bloodless  with  an  Esmarch  bandage,  then  placed  it  in  a 
plethysmograph  cylinder  filled  with  water  and  connected  with 
a  manometer.  When  the  compressing  band  was  removed,  the 
return  of  blood  to  the  arm  displaced  water  from  the  cylinder, 
and  automatically  registered  in  the  manometer  pressures,  from 
which  he  thought  the  maximum,  minimum,  and  mean  arterial 
pressures  could  be  read.  The  results  are  somewhat  question- 
able, the  application  abounds  with  opportunity  for  subjective 
mistakes,  if  the  reading  does  not,  and  the  apparatus  is  impos- 
sible outside  the  laboratory. 

V.  Recklinghausen  made  his  determinations  by  recording 
the  pulse  from  the  armlet  during  steadily  increasing  compres- 
sion, by  means  of  a  Fick  manometer  and  revolving  drum.  His 
manometer  was  standardized,  and,  by  comparing  the  portions 
of  the  "staircase  curve"  so  obtained,  he  determined  the  exact 
value  of  each  portion  of  the  pulse-wave,  from  this  reconstruct- 
ing a  pulse-wave  in  its  exact  measurement  expressed  in  pres- 
sures.    This,  also,  is  obviously  unsuited  to  general  imitation. 

Hensen,^  Masing,^  and  the  author,*  before  any  satisfactory 

^  Hiirthle,  K.  Ueber  eine  Methode  zur  Registierung  des  Arteriellen  Blut- 
druck  beim  Menschen.     Deutsch.  nied.  Wochenschr.,  1896,  p.  574. 

*  Hensen,  II.  Beitrage  zur  Physiologie  und  Pathologie  des  Blutdrucks. 
Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol.  Ixvii,  p.  438. 

*  Masing,  Ernst.  Ueber  das  Verhalten  des  Blutdrucks  des  jungen  und  des 
bejahrten  Menschen  bei  Muskelarbeit.  Deutsch.  Arch.  f.  klin.  Med.,  1902,  vol. 
Ixxiv,  p.  253. 

*  Janeway,  Theodore  C.  Some  Observations  on  the  Estimation  of  Blood- 
pressure  in  Man,  with  Especial  Reference  to  the  Results  obtained  with  the  Newer 
Sphygmomanometers.    N.  Y.  Univ.  Bull,  of  the  Med.  Sci.,  1901,  vol.  i,  p.  105. 


74  INDIRECT  MEASUREMENT  OF  BLOOD-PRESSURE 

clinical  method  for  determining  diastolic  pressure  had  been 
brought  forward,  endeavored  to  investigate  it  by  a  combination' 
of  sphygmographic  tracings  and  the  Riva-Rocci  apiDaratus. 
Masing  and  myself  used  an  identical  method,  independently  of 
one  another,  which  gave  merely  approximations  and  could  in 
no  way  be  recommended  to-day. 


CHAPTER   IV 
THE  MODERN  SPHYGMOMANOMETERS 

1.  Introduction. 

2.  Instruments  measuring  systolic  pressure  only. 

A.  Criterion  :   The  return  of  the  pulse- wave  under  com- 

pression. 

a.  General  construction. 

b.  General  method  of  use. 

c.  Riva-Rocei's  sphygmomanometer. 
Special  construction  and  technique. 
Advantages  and  defects. 

d.  Martin's  modification  with  Gumprecht's  manometer. 

e.  Coolc's  modification. 

Special  construction  and  technique. 
Advantages  and  defects. 

B.  Criterion  :    The   return   of   color  to  the   skin  of  the 

blanched  finger. 

a.  Gartner's  tonometer. 
Special  construction. 
Method  of  use. 
Advantages  and  defects. 

b.  Martin's  modification. 

3.  Instruments  measuring  diastolic  pressure. 

A.  Criterion :  Lowest  level  of  maximum  pulsation. 

a.  Hill  and  Barnard's  sphygmometer. 
Construction. 
Method  of  use. 
Advantages  and  defects. 

75 


76         THE  MODERN   SPHYGMOMANOMETERS 

4.  Instruments  measuring  systolic  pressure  (return  of  the  pulse), 

and    aiFording    an    approximate    estimate    of  diastolic 
pressure  (maximum  pulsation). 

a.  Stanton's  sphygmomanometer. 
Special  construction  and  technique. 
Advantages  and  defects. 

b.  Author's  sphygmomanometer. 
Special  construction  and  technique. 
Advantages  and  defects. 

5.  Instruments  measuring  accurately  both  systolic  pressure  (return 

of  the  pulse)  and  diastolic  pressure  (maximum  pulsa- 
tion) by  graphic  record. 

a.  Erlanger's  sphygmomanometer. 
Special  construction. 
Method  of  use. 
Advantages  and  defects. 

6.  Comparison  of  results  obtained  with  the  various  sphygmoma- 

nometers. 

7.  Blood-pressure  records. 

8.  Practical  suggestions. 

A.  The  choice  of  a  sphygmomanometer. 

B.  Minor  details. 


CHAPTER   IV 

THE  MODERN  SPHYGMOMANOMETERS 

1.    INTRODUCTION 

The  gradual  development  of  various  sphygmomanometers 
from  which  one  may  choose  a  clinical  instrument  to-day,  has 
been  unfortunate  in  breeding  more  partisan  bias  and  personal 
feeling  than  should  find  a  place  in  the  quest  of  scientific  accu- 
racy ;  but  this  evil  has  not  been  without  its  good  side.  It  has 
led  to  the  rigid  scrutiny  of  each  new  instrument  brought  for- 
ward, and  a  diligent  search  for  its  faults.  The  result,  we  have 
seen,  has  been  to  leave  the  method  of  circular  compression  in 
full  possession  of  the  field.  When  complying  with  the  require- 
ment that  the  compressing  surface  shall  bear  a  definite  propor- 
tion to  the  circumference  of  the  part  to  which  it  is  applied,  the 
error  involved  is  negligible  for  clinical  purposes.  The  values 
so  obtained  for  the  blood -pressure  are  comparable  from  indi- 
vidual to  individual,  and  are  almost  entirely  independent  of 
differences  in  the  soft  parts  overlying  the  vessel.  An  armlet 
of  12  cm.  width  is  adequate  for  any  but  the  most  enormous 
arms. 

The  investigations  which  have  led  to  this  conclusion  have 
been  of  recent  date,  and  practically  all  our  data  relating  to 
human  blood-pressure  are  from  instruments  using  a  narrower 
compressing  surface.  These  will  be  described  severally  in  the 
latest  form  in  which  they  are  purchasable,  but  no  instrument 
with  a  narrow  armlet  should  be  used.  One  may  easily  substi- 
tute a  wide  cuff  in  any  of  the  forms  described. 

2.    INSTRUMENTS    MEASURING    SYSTOLIC    END- 
PRESSURE    ONLY 

A.  Criterion:  The  Return  of  the  Pulse-wave  under  Compres- 
sion (see  page  62). — For  all  instruments  the  general  construc- 
tion and  method  of  use  are  the  same. 

77 


78         THE  MODERN   SPHYGMOMANOMETERS 

a.  General  Construction. — Essential  Parts:  A,  manom- 
eter; B,  compressing  armlet ;  C,  inflating  apparatus. 

Accessory  Parts  :  D,  connecting  tubing  with  air-tight 
joints;  E,  valve  or  pinch-cock  for  the  slow  release  of  pressure. 

b.  General  Method  of  Use. — The  armlet  is  fastened  snugly 
(see  page  5(j)  about  the  arm  or  thigh  at  the  level  of  the  heart 
(see  page  59).  On  the  thigh  this  necessitates  the  recumbent 
posture.  The  finger  ordinarily  used  for  palpating  the  pulse  is 
then  placed  on  the  radial,  or  the  dorsalis  pedis,  and  the  patient 
instructed  to  relax  the  limb  completely  (see  page  01).  With 
the  other  hand  the  pressure  is  then  raised  steadily  by  means  of 
the  inflating  apparatus.  When  the  volume  of  the  pulse  begins 
to  diminish,  the  pressure  is  increased  very  slowly  until  the 
pulse  disappears,  then  released  as  gradually  as  possible  until 
its  return  is  detected.  The  height  of  the  manometer  column 
at  which  this  occurs  is  noted,  and  the  pressure  raised  just 
enough  to  again  obliterate  the  pulse.  It  is  allowed  to  fall  a 
second  time  and  another  reading  made.  If  the  two  points  cor- 
respond within  5  mm.  of  one  another,  the  average  may  be  taken 
as  the  systolic  blood-pressure  at  the  time  of  observation.  If 
the  readings  fail  to  approximate  so  nearly,  one  must  wait  a 
couple  of  minutes  and  determine  anew. 

c.  Riva-Rocci's  Sphygmomanometer.^^ — Special  Construc- 
tion.-^A.  The  mercury  manometer  is  of  cistern  form.  The 
tube  carries  behind  it  a  metal  scale  graduated  in  millimeters 
from  40  to  200  mm.  The  cistern  is  of  heavy  glass  with  two 
tubes  entering  it,  one  for  the  attachment  of  the  inflating  bulb, 
the  other  for  the  tube  leading  to  the  armlet.  The  latter 
of  these  is  provided  with  a  screw-valve  (E)  for  the  gradual 
lowering  of  pressure.    The  whole  stands  on  a  solid  metal  base. 

B.  The  armlet  consists  of  a  hollow  rubl)er  tube  covered 
with  silk,  of  4i  cm.  diameter.  It  is  provided  with  a  special 
clamp  for  fastening  in  place  on  the  arm.  Near  its  closed  end 
is  inserted  a  small  tube  (D)  leading  to  the  manometer. 

C  C  '.  The  inflating  apparatus  is  a  Richardson  double  bulb, 
such  as  used  for  a  thermo-cautery. 

Special  Technique. — The  armlet  is  placed  about  the  arm 
and  the  open  end  socurcHl  firmly  in  the  clamj).  The  ])ressure 
is  best  raised  by  means  of  the  terminal  bulb  (C)  until  the  pulse 
»  Uiva-Rocci.    Gaz.  Med.  di  Torino,  1896,  Nos.  51,  53. 


MEASURING   SYSTOLIC   PRESSURE 


79 


has  nearly  disappeared,  then  the  iEinal  gradual  compression  and 
release  regulated  from  the  distended  second  bulb  (C).  This 
requires  some  practice  and,  for  high  pressure,  a  little  strength, 
but  it  saves  enough  time  to  be  worth  acquiring.  If  not  pos- 
sible, then  the  slow  lowering  of  pressure  must  be  accomplished 
with  the  screw- valve  (E). 

Advantages. — ^It  is  the   original  instrument.     The  ma- 
nometer stands  firmly  and  the  scale  is  easily  read.     It  is  not 


Fig.  21. — Eiva-Rocci's  spuygmomanometek. 


easily  broken.  The  armlet  can  be  neatly  adjusted.  The 
double  bulb  inflation  requires  no  special  knack. 

Defects. — The  manometer  is  not  easily  portable.  The 
armlet  possesses  the  fatal  defect  of  too  small  width  (see  page 
57).  The  double  bulb  as  an  inflator  consumes  an  unnecessary 
amount  of  time  and  is  not  very  durable.  The  connecting  tubes 
are  of  distensible  rubber. 

Makees. — Zambelli  &  Co.,  Turin,  Italy. 

Cost. — In  Germany,  45  marks.  Can  be  obtained  in  the 
United  States  only  by  importation. 


80         THE   MODERN   SPHYGMOMANOMETERS 

d.  Martin's^  Modification  with  Gumprecht's  Manometer. — This 
substitutes  a  manometer  with  glass  cistern  of  larger  capacity, 
in  order  to  make  the  zero  point  accurate;  also  a  10  cm.  armlet 
with  an  improved  clamp.  The  manometer,  armlet,  bulb,  and 
an  outlet  tube  closed  by  a  pinch-cock  are  connected  through  a 
4-way  glass  tube. 

This  overcomes  the  chief  defects  of  the  original  instrument, 
but  the  manometer  is  not  easily  portable. 
Makers. — Gehrike,  Jena,  Germany. 

e.  Cook's  Modification." — This  is  the  most  widely  used  instru- 
ment in  this  country  and  has  done  most  to  arouse  interest  in 
the  study  of  blood-pressure. 

Special  Construction. — A.  An  ingenious  portable  ma- 
nometer with  jointed  tube;  calibre  1  mm. 

B.  A  simple  and  cheap  armlet,  consisting  of  a  narrow  rub- 
ber bag,  4i  by  40  cm.,  covered  with  canvas  and  fastening  with 
hook  and  eye  under  a  band. 

C  C  '.  Richardson's  double  bulb  for  inflation. 

D.  A  glass  T  canula  joining  the  connecting  tubes  from 
manometer,  armlet,  and  bulb. 

E.  A  pinch-cock  on  a  small  branch  tube  for  the  release  of 
pressure.  This  is  introduced  near  the  manometer  by  means  of 
a  second  glass  T  canula. 

Special  Technique. — This  is  practically  the  same  as  for 
the  Riva-Rocci,  except  that  the  armlet  is  fastened  by  passing 
the  open  end  under  the  band  on  the  closed  end  and  hooking 
it  into  one  of  the  series  of  eyelets.  Care  must  be  used  to  see 
that  the  upper  joint  of  the  manometer  tube  is  inserted  securely. 
For  those  who  are  unable  to  control  the  pressure  from  the 
second  bulb  (C),  a  very  gentle  squeezing  of  the  pinch-cock 
will  allow  slow  escape  of  the  air.  In  packing  the  instrument, 
this  pinch-cock  must  be  placed  on  the  tube  connected  with  the 
neck  of  the  manometer  reservoir,  or  mercury  will  be  spilled. 

Advantages. — It  is  exceedingly  simple,  light  and  com- 
pact; therefore  well  fitted  for  general  clinical  use. 

Defects. — The  manometer  does  not  stand  firmly  and  is 

1  Martin,  Alfred.    Munch,  med.  Woclicnschr.,  1903,  L\  pp.  1021  and  1072. 

'Cook,  II.  W.  Blood-pressure  Determinations  in  General  Practice:  In- 
troducing a  Practical  Instrument  for  Routine  Use.  Jour.  Am.  Med.  Ass.,  1903, 
vol.  xl,  p.  1199. 


MEASURING   SYSTOLIC  PRESSURE 


81 


readily  broken,  at  least  in  my  experience.  Without  care  in 
packing,  the  mercury  is  apt  to  be  spilled.  The  scale  is  not 
easily  read  and  the  tube  calibre  is  too  small.  The  connections 
are  made  with  distensible  rubber  tubing.  All  these  defects 
would  be  compensated  for  by  its  simplicity  and  compactness, 
but  it  possesses,  hke  its  original  model,  the  serious  defect  of 
providing  much  too  narrow  an  armlet  (see  page  57).  Its  read- 
ings, therefore,  tend  to  be  too  high  in  all  adults,  much  too 


Fig.  22. — Cook's  sphygjiomanometee. 
(From  Cook  and  Briggs.) 


high  in  stout  ones.  In  children  this  does  not  enter  into  the 
consideration,  and  the  instrument  was  first  used  by  Dr.  Cook 
in  a  children's  hospital.  For  comparative  readings  on  the 
same  patient  the  error  wdll  be  constant  and  neghgible,  thus  it 
may  be  used  in  surgical  operations  and  acute  disease  for  fol- 
lowing variations  in  tension,  but  its  results  are  not  trustworthy 
for  diagnosis. 

Makers. — Eimer  and  Amend,  205-211  Third  Avenue,  New 
York  city. 

Cost. — Complete  in  case,  $8.50  net. 

They  also  make  a  form  with  one  piece  manometer  for  hos- 
pital use,  where  portability  is  unnecessary.     Cost,  $G.50  net. 
7 


82         THE   MODERN   SPHYGMOMANOMETERS 

An  instrument  practically  identical  with  Cook's  hospital 
form,  except  that  the  manometer  is  modelled  after  Gartner's, 
and  has  a  more  legible  scale  and  broader  foot,  is  made  by  The 
F.  H.  Thomas  Co.,  707  Boylston  Street,  Boston,  Mass.  This 
also  is  sold  at  $0.50  net.     It  is  not  portable. 

B.  Criterion:  The  return  of  color  to  the  skin  of  the  blanched 
finger  (see  page  00).  a.  Gartner's  Tonometer.* — ^This  is  the  only 
instrument  using  the  above  criterion.  Introduced  by  Prof.  Gart- 
ner in  the  summer  of  1899,  it  has  achieved  a  wide  popularity. 
In  its  essential  parts  it  does  not  differ  from  the  instruments  of 
the  Riva-Rocci  type,  save  that  the  circular  compression  is 
applied  by  a  ring  to  the  finger.  The  plate  shows  its  con- 
struction. 

Special  Construction. — A.  The  mercury  manometer,  of 
simple  cistern  form,  stands  firmly  on  a  broad  foot.  The  paste- 
board scale,  graduated  in  0.5  cm.  divisions  from  0  to  26  cm.,  is 
readily  seen  at  a  distance.  It  is  not  easily  carried,  and  for  this 
purpose  a  metal  manometer  is  furnished,  which  cannot  be 
trusted  without  frequent  standardizing. 

B.  The  pneumatic  ring,  the  original  feature  of  the  apparatus, 
consists  in  a  metal  ring  1.5  cm.  in  width,  lined  with  a  rubber 
membrane  which  leaves  a  hollow,  but  air-tight  space  between 
it  and  the  metal.  At  one  point  the  outer  ring  is  pierced  by  a 
metal  tube,  through  which  the  interior  air  space  is  connected 
with  a  tube  leading  to  the  manometer  and  inflator. 

C.  A  rubber  ball  or  bulb,  without  valve,  is  used  for  inflat- 
ing. The  slow  reduction  of  pressure  is  insured  by  placing  the 
ball  between  the  jaws  of  a  simple  vice  (E).  This  is  allowed  to 
open  slowly  by  turning  the  nut  which  runs  on  a  screw  thread. 
The  bulb  is  put  in  circuit  with  the  manometer  and  ring  by 
stiff  tubing  and  a  T  canula  (D). 

F.  A  compressor,  by  means  of  which  the  finger  can  be 
rendered  bloodless,  is  the  remaining  accessory.  It  consists  of 
a  rubber  membrane  stretched  over  the  head  of  a  small  metal 
cylinder. 

Method  of  Use. — A  pneumatic  ring  of  suitable  size  is 
placed  on  the  second  phalanx  of  the  middle  or  ring  finger, 
which  must  bo  at  the  level  of  the  heart  and  must  also  be  per- 
fectly warm.     The  last  phalanx  is  then  rendered  bloodless  by 

'  Gartner,  G.     Wien.  med.  Wochcusclir.,  1899,  vol.  xlix,  p.  1412. 


MEASURING   SYSTOLIC   PRESSURE 


83 


squeezing  the  compressor  over  it.  This  is  held  in  place  until 
the  pressure  in  the  ring  is  raised  above  the  expected  systolic 
blood-pressure  by  means  of  the  bulb.  The 
compressor  is  then  removed  from  the  fin- 
ger-tip and  the  vice  which  holds  the  bulb 
allowed  to  open  slowly.  As  it  does,  the  air 
gradually  returns  from  the  ring  into  the 
bulb  and  the  pressure  in  the  whole  system 
falls.  The  finger-tip  is  watched  intently 
and,  at  a  certain  point,  it  is  seen  to  flush 
suddenly;  then  the  height  of  the  manometer 
column  is  taken.  At  about  the  same  time 
the  patient  is  conscious  of  a  throb.  In  some 
cases,  if  the  pressure  be  reduced  very  gen- 
tly, the  throb  will  be  a  few  mm.  Hg.  lower 
than  the  first  fiush  and  will  be  accompa- 
nied by  a  deepen- 
ing of  it.  The 
manometer  read- 
ing at  the  instant 
the  color  returns 
represents,  with 
the  reservations 
made  heretofore 
(see  page  66),  the 
systolic  end-pres- 
sure in  the  digital 
arteries. 


/  C 


Fig.  23. — Gartner's  tonometer. 


Advantages. — In  most  cases  the  easy  perception  of  the 
return  of  color  to  the  finger  gives  this  method  a  strong  recom- 
mendation.    It  requires  no  special  skill  in  its  apphcation. 


84         THE  MODERN   SPHYGMOMANOMETERS 

Defects. — Unfortunately  these  are  numerous  enough  to 
outweigh  the  advantages,  and  the  majority  of  careful  observ- 
ers, in  this  country  as  abroad,  have  adopted  methods  which  can 
be  applied  to  the  arm.  These  defects  are  due  in  part  to  badly 
fitting  rings  (see  page  56),  unless  one  have  a  large  assortment 
of  sizes,  or  to  careless  application  (see  page  60);  in  part  to 
insufficient  width  of  the  compressing  surface  (see  page  59). 
Most  important  of  all,  and  least  remediable,  are  the  errors  in- 
herent in  all  methods  which  measure  blood-pressure  in  arteries 
so  small  and  so  near  the  periphery  as  the  digitals  (see  page  68), 
and  the  failure  of  the  criterion  to  work  in  a  certain  number  of 
patients. 

The  instrument  is  not  sufficiently  portable  for  all  purposes 
and  is  used  with  difficulty  on  unconscious,  delirious  or  anaes- 
thetized patients. 

Maker. — Franz  Hugershoff,  Leipzig,  Carolinenstrasse  13, 
Germany. 

Cost. — 25  marks  50  pfennig.  "With  metal  manometer,  35 
marks.  At  times  may  be  found  at  instrument  dealers  in  the 
United  States  without  special  importation. 

b.  Martin's  modification. — This  consists  only  in  the  substitu- 
tion of  a  small  modified  Riva-Rocci  tube,  of  2.5  cm.  width,  for 
the  pneumatic  ring.  Martin  ^  has  devised  a  special  clamp  for 
this  and  has  eliminated  the  technical  defects  of  the  instrument, 
but  not  the  errors  of  the  method. 

These  rings  may  be  had  of  Hanhart  &  Co.,  Zurich, 
Switzerland. 


3.    INSTRUMENTS  MEASURING   DIASTOLIC 
PRESSURE 

A.  Criterion:  Lowest  level  of  maximum  pulsation  (see  page 
69).  a.  Hill  and  Barnard's  Sphygmometer.^ — This  is  the  sole 
instrument  of  this  class  which  can  be  considered  a  modem 
sphygmomanometer,  OHver's  hsemodynamometer  emplojong 
the  faulty  v.  Basch  method  of  compressing  the  artery.     The 


'  Martin,  Alfred.     Miinch.  med.  Wochenschr.,  1903,  LS  ]\  1072. 
»  Hill,  Leonard,  and  Barnard,  Harold.     British  Med.  Jour.,  1897,  vol.  ii, 
p.  904. 


MEASURING   DIASTOLIC   PRESSURE 


85 


important  parts,  except  for  the  type  of  manometer  used,  are 
analogous  with  those  of  the  Riva-Rocci,  and  are  seen  in 
the  cut. 

Special  Construction. — A.  A  delicate  metal  manometer 
or  spring  tambour.  The  dial  is  graduated  in  recent  instru- 
ments from  30  to  250  mm.  Hg.,  each  subdivision  representing 
2  mm.  The  needle  magnifies  considerably  the  oscillations  of 
the  pulse- wave.  The  stem  of  the  manometer  has  a  lateral 
branch,  to  which  the  tube  leading  from  the  armlet  is  attached 
by  a  screw-cap  connection;  and  a  straight  branch,  to  which 
the  pump  is  attached. 

B.  The  armlet  consists  of  a  hollow  rubber  bag,  5  cm.  wide 
and  about  20  cm.  long,  with  the  connecting  tube  (D)  cemented 


Fig.  24. — Hill  and  Barnard's  spiitgaiometer. 


into  its  centre.  It  is  attached  to  an  outer  leather  cuff  which 
buckles  around  the  arm. 

C.  The  inflating  apparatus  is  a  pump,  like  a  hand  bicycle 
pump.     At  E  is  a  valve  for  the  slow  escape  of  the  air. 

Method  of  Use. — The  cuff  is  buckled  snugly  around  the 
arm,  with  the  same  precautions  as  for  the  Riva-Rocci  armlet, 
and  with  the  outlet  tube  directed  anteriorly.  The  pressure  is 
then  raised  slowly  and  steadily  with  the  pump.  Soon  the 
needle  will  be  seen  to  pulsate.  Its  oscillations  will  increase 
until  they  cover  a  number  of  millimeters  of  the  scale,  then 
gradually  decrease  as  the  pressure  is  further  raised.  The 
manometer  reading  at  which  they  first  become  most  extensive 
is  taken.     The  pressure  is  then  allowed  to  fall  slowly  by  turn- 


86         THE  MODERN   SPHYGMOMANOMETERS 

ing  the  wheel  which  releases  the  valve,  and  the  last  point  of 
greatest  oscillation  of  the  needle  is  noted  on  the  descent.  This 
should  correspond  closely  with  the  previous  reading  and  their 
average  represents  the  diastolic  pressure.  Hill  recommended 
taking  the  mid-point  of  maximum  oscillation,  which  he  thought 
corresponded  with  mean  blood-pressure,  but  this  is  an  indefinite 
guide  (see  page  69),  and  the  method  I  have  given  should  be 
followed. 

Advantages. — The  construction  and  finish  of  the  instru- 
ment are  admirable;  it  is  easily  carried  in  its  leather  case,  is 
not  difficult  to  use,  and  seemed  at  first  an  almost  ideal  clinical 
method. 

Defects. — Like  all  delicate  metal  manometers,  the  readings 
tend  to  become  inaccurate.  One  which  I  used  during  1900  and 
1901,  registered  26  mm.  too  high  at  the  end  of  a  year.  It 
needs  to  be  standardized  frequently  by  comparison  with  a 
mercury  manometer,  which  is  irksome.  The  manometer  is 
also  difficult  of  repair  in  this  country,  a  considerable  draw- 
back to  so  costly  an  apparatus.  It  has  the  narrow  cuff,  with 
its  inherent  errors ;  though  a  wide  one  might  of  course  be  sub- 
stituted for  it.  In  addition,  in  certain  important  cases,  such  as 
aortic  insufficiency  and  high  tension,  the  determination  of  the 
exact  lower  limit  of  maximal  oscillation  is  not  always  easy,  and 
I  am  inclined  to  the  view  that,  for  clinical  purposes,  the  knowl- 
edge of  diastolic  pressure  alone  is  not  so  valuable  as  that  of 
systolic.  The  latter  may  be  determined  with  this  instrument, 
as  with  the  Riva-Rocci,  by  the  disappearance  or  return  of  the 
pulse;  but  the  upper  limit  of  use,  240  mm.,  has  not  sufficed  for 
many  cases  in  my  experience.  The  statement  made  by  some 
who  use  it,  that  systolic  pressure  corresponds  with  the  point  at 
which  the  needle  no  longer  shows  movement,  is  quite  mistaken. 
Marey,  in  his  original  work  on  the  subject  (see  page  50), 
pointed  this  out,  and  Howell  and  Brush  ^  have  demonstrated  it 
conclusively.  With  a  maximum  manometer  in  the  artery, 
they  found  the  pulse- wave  carried  over  to  the  sphygmomanom- 
eter as  much  as  20  mm.  beyond  the  level  of  maximum  pres- 
sure. This  undoubtedly  is  due  to  the  fact  that  only  the  middle 
of  the  portion  of  artery  under  the  bag  is  compressed,  the  upper 

'  Howell  and  Brush.    Boston  Med.  and  Surg.  Jour.,  1901,  vol.  cxlv,  p.  146. 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS    87 

part  still  remaining  open  and  the  pulse  in  it  striking  against 
the  armlet.^ 

Makers. — J.  Hicks,  London,  Eng. ;  agents  for  the  United 
States,  Oelschlager  Bros.,  42  East  Twenty -third  Street,  New 
York  city. 

Cost. — In  the  United  States, 


4.  INSTRUMENTS  MEASURING  SYSTOLIC  PRESSURE 
(Return  of  the  Pulse)  AND  AFFORDING  AN  APPROX- 
IMATE ESTIMATE  OF  DIASTOLIC  PRESSURE  (Max- 
imum Pulsation) 

By  using  an  armlet  whose  expansion  outward  is  entirely 
hindered  by  a  stiff  cuff,  connected  with  a  wide  calibre  manom- 
eter by  stiff- walled  tubing,  the  pulse- wave  can  be  transmit- 
ted to  the  mercury  column.  The  latter  does  not,  of  course, 
follow  the  cardiac  variations  in  arterial  pressure  quantitatively 
(see  page  5),  but  the  movements  of  the  mercury  are  of  suffi- 
cient extent  to  make  an  approximate  reading  of  the  lower 
limit  of  maximum  oscillation  possible.  With  rapid  and  small 
pulses  this  becomes  difficult  or  impossible,  but  in  the  average 
case  the  column  fluctuates  6  mm.  to  10  mm.  at  its  greatest. 
In  pulses  of  high  tension  and  in  aortic  insufficiency,  where  a 
knowledge  of  diastolic  as  well  as  systolic  pressure  is  especially 
important,  the  column  may  show,  as  in  a  case  I  observed  re- 
cently, a  pulse  movement  of  as  much  as  40  mm. 

Two  instruments  recently  brought  forward  in  this  country 
have  the  requisite  construction  for  this  purpose. 

A.  Stanton's  Sphygmomanometer.^ — Special  Construction. 
— Stanton  was  the  first  in  this  country  to  adopt  the  wider  armlet 
and  to  construct  a  clinical  instrument  free  from  serious  defect. 
His  sphygmomanometer  differs  from  the  Riva-Rocci  chiefly  in 
the  compressing  and  inflating  devices.  The  former  (F)  is  a 
hollow  rubber  bag,  3i  inches  (8  cm.)  wide  and  16  inches  long, 
closed  at  both  ends,  and  prevented  from  expanding  outward 
by  a  cuff  of  double  thick  canvas,  reinforced  by  tin  strips,  A 
glass  connecting  tube  is  inserted  at  the  centre  of  the  rubber 

*  See  diagram  page  57.  The  portion  of  artery  ABC  would  not  be  com- 
pletely collapsed. 

»  Stanton,  W.  B.    Univ.  of  Penn.  Med.  Bull.,  1903,  vol.  xv,  p.  466. 


88 


THE   MODERX   SPHYGMOMANOMETERS 


bag  by  means  of  a  hollow  valve  stem,  such  as  is  used  for  bi- 
cycle tires.  This  is  connected  by  the  stiff- walled  rubber  tube 
(G)  with  the  manometer,  which  consists  of  a  metal  cistern 
(C)  connected  by  a  metal  tube  "with  the  glass  upright  tube  and 
scale  (D),  which  can  be  unscrewed  for  carrying.  The  relative 
diameters  of  cistern  and  column  are  100  to  1,  thus  affording 
an  accurate  zero  point.  The  cistern  (C)  is  covered  by  a  screw- 
cap  with  a  T-tube,  one  branch  of  which  connects  with,  the 
armlet,  the  other  vrith  the  bulb.     At  B  is  a  screw  valve  for 


Fig.  25.— Staxton's  sphtgmomakometeb. 
(Cut  from  The  Arthur  II.  Thomas  Co.) 

gradual  release,  at  A  a  stop-cock  to  shut  off  the  inflator. 
Stanton  uses  a  single  rubber  bulb,  such  as  is  found  on  atom- 
izers, for  the  latter. 

To  carry  the  apparatus,  the  bulb  is  removed  from  the  T  at  1 
and  the  cap  1  screwed  in,  cap  2  similarly  closing  the  other 
entrance  2,  from  which  the  armlet  and  tube  G  are  discon- 
nected. The  manometer  is  then  tilted  on  its  side  until  the 
mercury  lias  all  run  into  the  cistern,  the  upright  glass  tube  is 
un.screwed,  and  its  place  filled  bj'  the  cap  3. 

Special  Technique. — The  methods  of  estimating  systolic 
and  diastolic  pressures  are  the  same  as  those  described  for  the 
Riva-Rocci  and  Hill   and   Barnard  instruments  respectively. 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS    89 

The  armlet  is  applied  snugly,  folding  in  any  extra  length  of 
the  rubber  cuff,  if  the  arm  be  small.  The  manometer  column 
should  be  inspected  to  see  that  it  stands  at  0,  the  armlet  then 
connected  with  the  manometer,  the  valve  (B)  closed,  and  the 
stop-cock  (A)  opened.  The  bulb  is  squeezed  as  shown  until 
the  pulse  disappears,  when  the  stop-cock  (A)  is  closed.  The 
pressure  is  gradually  lowered  by  unscrewing  B,  noting  the  re- 
turn of  the  pulse  and  the  lowest  point  at  which  maximum 
pulsation  of  the  mercury  occurs.  The  precautions  necessary 
in  noting  the  oscillation  of  the  mercury  will  be  explained  in 
connection  with  the  author's  sphygmomanometer. 

Advantages. — The  greatest  recommendation  of  this  in- 
strument is  the  fact  of  its  throwing  light  on  the  diastolic  pres- 
sure, while  measuring  the  systolic  with  the  same  ease  as  the 
ordinary  forms  of  the  Riva-Rocci.  Of  course  it  does  not  give 
measurements  which  compare  with  those  of  Erlanger's  graphic 
method,  or  Mosso's,  but  the  latter  are  unquestionably  too 
bulky  and  too  elaborate  for  general  use.  This  sphygmoma- 
nometer also  has  an  armlet  wide  enough  for  the  majority  of 
cases,  though  not  so  absolutely  free  from  error  as  a  12  cm.  one. 

Defects. — It  seems  to  me  unfortunate  not  to  adopt  the 
full  12  cm.  armlet,  for  on  arms  of  over  30  cm.,  and  they  are 
not  very  rare,  some  error  must  be  present.  I  must  admit  the 
awkwardness  of  the  wider  cuff,  but  this  should  be  a  minor 
consideration.  Beyond  this,  the  instrument  possesses  no  de- 
fect, save  that  it  is  not  quite  so  readily  portable  as  those  devised 
by  Cook  and  by  the  author.  It  is  an  excellent  and  ingenious 
clinical  instrument. 

Makers. — The  Arthur  H.  Thomas  Co.,  southwest  corner 
Twelfth  and  Walnut  Streets,  Philadelphia,  Pa. 

Cost. — Complete  in  carrying  case,  $20. 

B.  The  Author's  Sphygmomanometer. — Special  Construc- 
tion.— This  instrument  was  devised  by  me  after  much  hesita- 
tion, for  I  had  no  wish  to  increase  the  number  of  existing 
sphygmomanometers.  It  was  the  result  of  a  desire  to  possess 
a  really  portable  clinical  instrument  in  which,  nevertheless,  no 
essential  accuracy  should  be  sacrificed.  The  only  original 
feature  is  the  folding  U  tube  manometer  (A).  This  is  shown 
in  the  plate  in  position  for  use.  For  carrying,  the  upper  joint 
of  the  manometer  tube  is  removed  and  shpped  through  the 


90 


THE   MODERN   SPHYGMOMANOMETERS 


rings  to  the  right.     The  open  end  of  the  U  is  then  closed  by  a 
small  cork  (F) ;  the  other  end  is  closed  automatically  when  the 


Fui.    20. — AUTllOll'.S    SI'IIYOMOMANDMETEU. 


case  is  shut,  by  a  block  which  compresses  the  rubber  joint 
(G).  The  scale  is  slid  down,  the  Politzer  bag  (C)  removed 
from  the  stop-cock  (E),  which  contains  a  needle-valve  for  slow 
release  of  pressure.     This  stop-cock  is  allowed  to  slip  under  a 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS    91 

spring  (H),  as  the  case  closes.  The  hd,  to  the  under  side  of 
which  the  manometer  is  fastened,  is  then  closed  by  dropping 
the  catches  which  hold  it  behind  and  folding  down  the  hinge 
at  the  left,  the  lower  end  of  the  lid  sliding  back  in  a  groove. 
The  whole,  when  closed,  measures  lOi  X  4|  X  1^  inches  and, 
with  the  armlet  and  inflator,  weighs  3^  pounds.  The  manom- 
eter tube  has  a  calibre  of  3  nnn.  and  all  the  connections  are 
of  heavy  pressure  tubing.  The  armlet  (B)  is  a  hollow  rubber 
bag,  12  cm.  wide  by  18  cm.  long,  with  an  outer  leather  cuff 
15  X  33  cm.,  fastened,  as  the  illustration  shows,  by  two  straps 
with  friction  buckles  which  will  catch  at  any  point.  The 
buckle  employed  makes  adjustment  to  different  arms  much 
easier  than  the  ordinary  tongue  buckle.  Experience  with  the 
latter  has  taught  me  that  one  hole  may  be  too  tight  and  the 
next  too  loose.  For  the  inflating  mechanism  I  have  followed 
Erlanger  in  adopting  the  ordinary  Politzer  bag,  though  I  find 
one  with  the  valve  necessary  to  fill  the  12  cm.  armlet.  The 
needle- valve  is  manipulated,  with  ease,  even  by  a  novice, 
and  allows  a  very  gradual  or  a  sudden  lowering  of  pressure 
equally  well. 

As  accurate  manometer  tubes  cannot  be  made  in  this  coun- 
try, each  scale  is  graduated  empirically,  the  reading  at  each 
point  being  the  exact  difference  between  the  level  of  the  two 
columns  of  mercury.     The  instruments  are  therefore  accurate. 

Special  Technique. — The  procedure  in  general  is  the 
same  as  with  Stanton's  instrument.  The  armlet  is  buckled  on, 
overlapping  the  ends  if  the  arm  be  small.  The  outlet  tube 
should  be  directed  anteriorly.  The  scale  of  the  manometer  is 
then  set  with  the  zero  point  at  the  level  of  the  two  mercury 
columns,  and  the  security  of  the  upper  joint  of  the  tube  tested. 
The  finger  ordinarily  used  for  palpating  the  pulse  is  then 
placed  on  the  artery  at  the  wrist.  If  the  left  hand  is  employed 
for  this,  the  left  arm  of  the  patient  should  be  used.  The  other 
hand  grasps  the  Politzer  bag  firmly  and  raises  the  pressure 
until  the  pulse  is  obliterated,  then  releases  it  very  slowly  and 
steadily  until  it  returns.  This  gives  the  systolic  pressure. 
With  high  tension  pulses  the  Politzer  bag  may  not  contain  air 
enough  to  raise  the  pressure  to  the  point  of  obliteration,  as  the 
12  cm.  armlet  has  a  considerable  cubic  volume.  If  this  is 
found,  close  the  stop-cock  (E)  while  the  Politzer  refills,  then 


92         THE   MODERN   SPHYGMOMANOMETERS 

open  slowly  while  squeezing  the  Politzer,  and  the  pressure  can 
be  carried  as  high  as  desired.  Then  close  the  stop-cock,  place 
the  finger  on  the  pulse,  and  with  the  other  hand  open  the  cock 
slowly  until  the  air  begins  to  escape  through  the  needle- valve. 
In  this  way  lower  the  pressure  very  gradually  until  the  return 
of  the  pulse  is  detected.  Then  carry  the  pressure  a  little 
higher  and  repeat.  This  time,  after  the  pulse  is  detected, 
allow  the  pressure  to  fall  5  or  10  mm.  at  a  time  until  the  lowest 
point  of  maximum  oscillation  of  the  manometer  column  is  de- 
termined. If  any  air  remains  in  the  apparatus,  remove  the 
Politzer  bag  and  it  will  escape.  One  precaution  must  be  ob- 
served, namely,  to  allow  time  after  each  fall  in  pressure  for  the 
mercury  to  recover  from  the  procedure,  before  comparing  its 
oscillations  with  those  at  the  previous  level.  If  the  drop  has 
been  sudden  there  will  be  a  rebound  of  the  column,  which  will 
make  the  first  few  pulsations  abnormally  large.  The  respira- 
tory variations  in  size  of  the  pulse  are  quite  evident  in  some 
patients,  and  at  least  ten  to  twenty  oscillations  should  be  ob- 
served at  each  level  to  obtain  an  average.  I  think  it  usually 
wise  to  make  a  rough  approximation  first,  by  allowing  the 
pressure  to  fall  10  mm.  at  a  time;  then,  after  releasing  all  the 
pressure,  to  return  to  just  above  the  point  thus  determined  and 
make  a  careful  estimation  at  5  mm.  intervals.  When  the 
greatest  fluctuation  of  the  column  does  not  exceed  5  mm.,  it  is 
not  possible  to  form  any  judgment,  and  the  same  holds  good 
when  the  pulse  is  very  rapid.  Too  small  amplitude  of  pulsa- 
tion is  a  direct  effect  of  a  loose  adjustment  of  the  cuff,  and  this 
should  be  inspected  before  giving  up  the  attempt  to  find  the 
diastolic  pressure. 

Advantages  and  Defects.  —  These  will  perhaps  be 
brought  out  more  clearly  in  the  hands  of  others.  As  a  port- 
able sphygmomanometer  it  is  second  only  to  Cook's,  which  has 
not  proved  substantial  in  my  hands  or  those  of  my  hospital  in- 
ternes, and  which  also  lacks  the  wide  armlet.  It,  and  Stan- 
ton's form,  are  the  only  simple  instruments  with  which  one 
may  approximate  diastolic  pressure,  besides  measuring  sys- 
tolic. It  seems  to  me  more  compact  and  portable  than  the 
latter,  as  well  as  less  complicated  and  expensive.  I  might  add 
that  no  attempt  has  been  made  to  have  the  case  contain  the 
non-breakable  armlet  and  inflator,  which  would  add  materially 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS   93 

to  the  weight.  These,  with  the  manometer,  will  fit  in  the 
bottom  of  any  common  hand-bag,  with  one's  other  instru- 
ments. 

Makers. — Charles  E.  Dressier  &  Bro.,  145  East  Twenty- 
third  Street,  New  York  city. 

Cost. — Complete,  $14.00. 

For  my  hospital  use  I  have  designed  a  similar  instrument, 
but  with  one-piece  manometer,  and  a  box  which  does  not  close. 
Mr.  Dressier  can  make  these  to  order. 

For  physiological  instruction  in  medical  schools,  the  armlet 
and  inflator  can  easily  be  attached  to  the  regular  laboratory  ^ 
manometers. 

5.  INSTRUMENTS  MEASURING  ACCURATELY  BOTH 
SYSTOLIC  PRESSURE  (Return  of  the  Pulse)  AND 
DIASTOLIC  PRESSURE  (Maximum  Pulsation)  BY 
GRAPHIC  RECORD. 

Erlanger's  Sphygmomanometer.^ — In  its  improved  form  this  is 
one  of  the  latest,  and  certainly  is  the  most  accurate  addition  to 
our  means  of  determining  human  blood-pressures.  It  employs 
the  same  criteria  as  the  previous  instruments,  but  the  return 
of  the  pulse  and  the  point  of  maximum  pulsation  are  both 
made  so  clearly  visible,  that  the  subjective  errors  are  min- 
imized. 

Special  Construction. — The  mechanism  of  this  instru- 
ment is  more  complicated  than  of  those  previously  described, 
and  thoroughly  original,  but  the  only  essential  difference  is  the 
addition  of  a  recording  device.  Fig.  27  shows  the  whole  appa- 
ratus in  perspective.  The  U-tube  manometer  connects  with  a 
4-way  tube,  one  branch  of  which  leads  to  the  armlet,  another 
(F)  to  the  special  stop-cock  (C  D),  which  will  be  described 
later,  and  through  it  to  the  inflator.  The  vertical  branch  (to 
PS)  communicates  with  the  interior  of  a  rubber  bulb  (B),  en- 
closed in  a  heavy  glass  bulb  (G),  like  Marey's  sphj^gmoscope, 
which,  under  certain  conditions,  opens  freely  to  the  atmosphere 
through  the  tube  E.  The  object  of  this  device  is  to  shield  the 
delicate  tambour  from  too  sudden  changes  of  pressure,  which 

1  Erlanger,  Joseph.  Am.  Jour,  of  Physiol.,  1904,  vol.  x,  Proceed,  of  Am. 
Physiol.  Soc,  p.  xiv. 


To  Att 


To   InjlaVor 


FlO.    27. — EULANOEK'S    SriIYOMOMANOMBTER. 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS   95 

might  rupture  the  diaphragm.  The  tambour  is  connected  with 
the  air  enclosed  in  the  glass  bulb  (G),  and  inscribes  its  pulsa- 
tions by  an  aluminum  lever,  as  an  ample  tracing  on  the  re- 
volving drum.  The  pinion  designated  in  the  figure  allows  the 
tambour  to  be  rotated,  so  that  the  lever  may  be  brought  to 
bear  on  the  drum,  or  removed  from  it.  The  tracing  is  made 
on  smoked  paper,  instead  of  black  on  white,  as  the  figure,  on 
account  of  the  technical  limitations  of  a  line  drawing,  repre- 
sents it.  The  drum  has  two  speeds,  the  faster  obtained  by 
removing  the  fan,  and  is  controlled  by  a  lever,  which  projects 
through  the  slot  on  the  face  of  the  box  covering  the  clock- 
work. The  base  and  back  are  of  wood,  and  a  wooden  cover  is 
provided  for  carrying,  with  a  han- 
dle on  its  top.     The  whole  appara-  X^         '~""\ 

tus  is  considerably  larger  than  an  /^  '^^vClT" ^'^ 

ordinary  microscope  and  case,  and         /^  /c\,K~-    ^\       \ 
of  about  the  same  weight.  /        |''''<f^:l^.y^%■....J^.xi= 

The   compressing  armlet  is  a    ^  "'\z. \?V.  <,•  \V-^."7 f 

rubber  bag,  12  by  16  cm.,  with  an  N,       ^^^i^^A  Y^  ^^/ 

outer   leather    cuff,   fastening  by  v.  ^/         \\  j^ 

three  buckles.     A  Politzer  bag  is  ^ "^^ 

used    for    inflation.    ^  All    rubber      p,^  ss.-d.aorammatic  view  of 
tubing    is    the    heaviest     obtain-  stop-cock  from  above. 

able,  so  that  no   loss  of   the    pulse-  (From  Dr.  Erlanger's  drawing.) 

wave  occurs  during  transmission. 

The  details  of  the  stop-cock  and  recording  mechanism  may 
be  more  easily  explained  by  reference  to  the  mechanical  draw- 
ings, kindly  loaned  me  by  Dr.  Erlanger.  The  former,  in  which 
the  whole  technique  of  use  centres,  is  the  most  ingenious  feat- 
ure of  the  apparatus.  It  consists  of  a  brass  plug  C,  fitting  in 
a  barrel  which  is  surmounted  by  a  dial  D.  Fig.  28  shows  this 
from  above.  The  head  of  the  plug  (C)  carries  a  jDointer  (P), 
the  shaft  of  which  terminates  at  its  opposite  end  in  a  pawl  (R). 
This  pawl  catches  lightly,  with  a  click,  like  the  triple  nose- 
piece  of  a  microscope,  in  certain  grooves  on  the  dial.  The 
grooves  mark  important  positions  of  the  stop-cock,  and  are 
designated  "  In,"  "  Out,"  1  and  2.  At  any  intermediate  point, 
no  connection  exists  through  the  stop-cock,  and  the  manom- 
eter, tambour,  and  armlet  inake  a  closed  circuit,  the  tambour 
then  registering  the  pulsation  in  the  arm,  and  the  manometer 


96 


THE  MODERN   SPHYGMOMANOMETERS 


the  absolute  height  of  pressure  in  the  whole  system.  The  mi- 
nute opening  (O)  in  the  tambour,  prevents  suction  on  the  dia- 
phragm during  slow  release  of  the  pressure,  but  it  is  too  small 


FlO.    21). — DiAOKAMMATIO    SECTION    OF     ErLANOEr's     SPM VOMOMANOMKTKK. 

Stop-cook  at  position  "IN." 

Above  and  below  tlie  vertical  median  Bcction  of  stop-cock  are  horizontal  sections, 
tlie  upper  at  level  of  tube  E,  the  lower  at  level  of  tube  F.  (From  Dr.  Erlanger's 
drawing.) 

to  influence  the  trace  caused  by  the  rapid  pressure  variations 
of  the  pulse-wave.  When  the  pointer  is  set  at  "  In,"  as  in 
Fig.  28,  the  stop-cock  makes  the  connection  shown  in  Fig.  29. 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS   97 


The  manometer,  armlet,  and  pressure  space  (PS),  inside  the 
rubber  bulb  (B),  are  in  circuit,  through  the  tube  (F),  with  the 
inflator  attached  to  the  tube  "  In."  The  air  within  the  glass 
bulb  (G)  which  communicates  with  the  tambour,  marked  T  S 
(tambour  space),  is  open  freely  to  the  exterior  through  the 
tube  (E),  which  connects  with  a  vertical  bore  in  the  center  of 
the  stop-cock  (C).     Thus,  as  the  pressure  in  the  apparatus  is 


IZIE 


Fig.  30. — Diagrammatic  sections  of 
STOP-COCK,  AS  IN  Fig.  29.  Position 
"OUT."  (From  Dr.  Erlanger's 
drawing.) 


Fig.  31. — Diageammatio  sections  of 
stop-cock,  as  in  Fig.  29.  Posi- 
tion 1.  (From  Dr.  Erlanger's  draw- 
ing.) 


raised  and  the  bulb  (B)  expands,  air  is  displaced  out  of  T  S, 
and  the  lever  of  the  tambour  does  not  change  its  position, 
except  for  a  moment.  By  a  slight  turn  of  the  stop-cock  all 
these  connections  are  broken,  and  the  lever  (L)  begins  to 
write,  for  the  pulsations  of  the  arm  are  reproduced  by  the 
bulb  (B),  and  the  air  forced  in  and  out  of  T  S  can  only  go  to 
the  tambour. 

Fig.  30  shows  the  position  "  Out."     Here  the  inflator  is  cut 
off,  the  tube  (F),  which  leads  to  the  whole  manometer  system, 


98         THE  MODERN  SPHYGMOMANOMETERS 

opens  to  the  air  through  a  bore  in  the  bottom  of  the  stop-cock, 
and  T  S  again  communicates  with  the  exterior  through  E.  In 
this  position  the  pressure  on  the  arm  is  immediately  removed, 
but  the  tambour  is  protected  from  the  violent  change. 

Fig.  31  shows  position  1,  which  is  used  for  the  slow  release 
of  pressure  in  making  measurements.  The  pressure  space 
(P  S)  inside  B,  communicates  with  the  fine  capillary  1,  in  the 
bottom  of  the  plug  (C).  The  air  escapes  gradually  through 
this,  and  the  bulb  B  becomes  smaller.  The  tambour  head  and 
lever  sink,  until  the  pressure  in  T  S  becomes  so  much  less  than 
the  atmospheric  pressure,  that  air  begins  to  enter  through  the 
pinhole  (O).  The  lever  then  ceases  falKng,  and  may  even  rise 
as  the  pressure  slowly  becomes  equalized.  The  lever  continues 
writing  throughout  all  this  procedure,  reproducing  the  pulse- 
pressure  changes  of  B  in  undiminished  magnitude.  Position  2 
is  the  same,  except  that  the  capillary  is  a  little  larger,  and  the 
fall  in  pressure  more  rapid. 

Method  of  Use. — The  armlet  and  inflator  are  attached  to 
the  tubes  so  designated  in  Fig.  27.  The  clockwork  is  wound. 
The  drum  is  removed,  covered  with  the  glazed  paper  provided 
for  the  purpose,  and  lightly  smoked.  This  is  done  by  revolv- 
ing it  rapidly  in  the  sooty  flame  of  a  fish-tail  gas-burner,  or 
lamp,  or  of  burning  camphor.  The  smoked  cylinder  is  then 
set  in  place,  and  the  instrument  is  ready  for  use. 

Turn  the  stop-cock  to  "  Out,"  and  adjust  the  armlet  snugly. 
Then  rotate  the  stop-cock  to  "  In,"  and  raise  the  pressure  rapidly 
by  squeezing  the  inflator.  The  systolic  pressure  may  be  esti- 
mated in  the  usual  way,  by  palpating  the  pulse,  as  with  the 
Riva-Rocci  type  of  instrument ;  or  Erlanger's  graphic  method 
may  be  adopted  (see  pages  78  and  G4).  Not  all  cases  lend 
themselves  to  this,  in  my  experience,  and  the  palpation  of  the 
return  of  the  pulse  may  be  necessary.  For  the  other  method, 
raise  the  pressure  well  (about  50  mm. )  above  the  systolic  pres- 
sure, then  turn  the  stop-cock  to  an  intermediate  point  for  a  few 
seconds.  The  pressure  will  fall  slightly,  owing  to  adjustment 
of  the  cuff,  etc.  The  lever  will  show  small  oscillations.  Bring 
the  lever  to  bear  on  the  drum,  by  turning  the  pinion-screw, 
and  set  the  drum  in  motion.  Now  turn  the  stop-cock  to  1  or  2, 
preferably  the  latter,  after  one  has  become  expert.  The  lever 
will  at  first  be  depressed,  then  rise  slowly,  and  the  tracing  will 


SYSTOLIC   AND   DIASTOLIC   MEASUREMENTS  99 

gradually  increase  in  amplitude.  The  tracing  and  the  ma- 
nometer must  both  be  closely  watched,  and  the  moment  the 
pressure  falls  below  the  systolic  pressure  in  the  artery,  the 
tracing  will  show  an  abrupt  increase  in  size,  usually  with  a 
depression  of  the  lever  (see  Fig.  20).  The  manometer  must 
be  read  off  at  this  point,  which  gives  the  systolic  pressure. 
This  abrupt  change  is  clearer  with  the  more  rapid  fall  of  pres- 
sure through  capillary  2,  but  it  requires  more  practice  to  read 
the  manometer  at  the  exact  moment.  To  determine  the  dia- 
stolic pressure,  allow  the  air  to  continue  escaping  slowly  until 


Fig.  32. — Tracing  from  a  high  tension  pulse  by  Eelangek's  Sphygmomanometer. 

At  210  mm.  the  return  of  the  pulse  indicated  systolic  pressure,  though  the  trace  does 

not  show  the  abrupt  increase  clearly. 
At  135  mm.  is  the  lowest  limit  of  maximal  pulsation;  diastolic  pressure  (marked  Min.). 

the  pulsations  show  a  distinct  decrease  in  amplitude.  The  last 
point  at  which  they  are  of  maximum  height  is  the  diastolic 
pressure  (see  page  69). 

During  the  fall  in  pressure,  a  decrease  in  ampUtude  often 
occurs  shortly  after  the  systolic  pressure  has  been  reached, 
with  subsequent  increase.  Fig.  32  shows  these  two  maxima. 
The  lower  is  unquestionably  at  the  diastolic  pressure.  Erlan- 
ger  considers  the  first  decrease  due  to  the  rapid  re-entrance  of 
blood  to  the  arm,  the  later  increase  coming  when  the  vessels 
have  been  fully  distended.  This  method  gives  a  close  ap- 
proximation of  diastolic  pressure,  but  the  following  is  more 
accurate. 


100       THE   MODERN   SPHYGMOMANOMETERS 

Raise  the  pressure  a  little  above  the  approximate  diastolic, 
and,  by  manipulating  the  stop-cock,  allow  it  to  fall  by  steps  of 
5  mm.,  with  the  drum  at  slow  speed.  Take  a  record  of  ten  or 
twenty  pulses  at  each  point,  and  the  lowest  pressure  at  which 
maximum  amplitude  of  pulsation  is  obtained  will  be  very 
evident,  as  in  Fig.  33. 

Advantages. — This  is  unquestionably  the  most  accurate 
sphygmomanometer  obtainable.  It  is  also  the  best  from  the 
standpoint  of  workmanship.  F(jr  the  elucidation  of  physio- 
logical problems  relating  to  human  blood-pressure  it  is  the  ideal 
instrument. 

Defects. — The  only  fault  to  be  found  with  the  apparatus 
is  from  the  side  of  clinical  availabihty.  It  is  bulky,  and  im- 
possible to  use  in  private  practice,  save  in  one's  office.  There, 
and  in  the  hospital,  I  have  employed  it  with  much  satisfaction. 
It  requires  considerable  practice  to  work  it  easily,  and  to  keep 
it  in  good  order.  Smoking  the  cyhnder,  and  some  of  the 
other  details,  consume  more  time  than  can  always  be  spared 
in  practice,  but  the  actual  measurements  take  no  longer  than 
with  any  other  instrument. 

Makers. — The  Southern  Specialty  Company,  2043  HoUins 
Street,  Baltimore,  Md. 

Cost. — $37.50  complete. 

6.    COMPARISON  OF   RESULTS  OBTAINED   WITH 
THE  VARIOUS  SPHYGMOMANOMETERS 

A  uniform  method  of  blood-pressure  measurement  is  much 
to  be  desired,  and  will  certainly  come  with  the  general  adop- 
tion of  the  12  cm.  armlet.  In  the  meantime,  reports  of  blood- 
pressure  observations  by  various  methods  continue  to  be  pub- 
lished. The  difference  in  the  readings  is  sometimes  striking, 
particularly  when  figures  from  the  Hill  and  Barnard  or  Mosso 
instruments  are  compared  with  those  of  s3'stolic  pressure  de- 
terminations. The  usual  readings  from  Hill  and  Bafnard's 
sphygmometer  are  neither  diastolic  nor  systolic  pressure,  and 
cannot  be  compared  with  anything,  so  far  as  absolute  values 
are  concerned. 

Of  the  forms  giving  systolic  pressure,  all  those  using  the 
narrow  armlet  afford   higher   readings.     For  ordinary   arms 


BLOOD-PRESSURE   RECORDS  101 

and  normal  tensions,  this  overestimation  amounts  to  10  to  25 
mm.  With  marked  hypertension  and  a  large  arm,  I  have 
found  a  difference  of  GO  mm.  In  children  a  5  cm.  armlet  is 
suflficient.  This  means  that  one  should  know  both  circumfer- 
ence of  arm  and  tension,  in  order  to  correlate  the  figures, 
rather  a  difficult  condition  to  fulfil. 

Comijarison  of  Gartner's  tonometer  with  Riva-Rocci's 
sphygmomanometer,  by  Hayaski,^  showed  a  lower  estimation 
with  the  tonometer.  The  usual  discrepancy  was  20  mm. ;  the 
greatest  30  mm. ;  the  least  16  mm.  In  normal  cases  Gartner's 
tonometer  would  more  nearly  equal  the  readings  with  a  wide 
cuff,  but  with  higher  tension  the  tonometer  also  tends  to  over- 
estimate. 

7.    BLOOD-PRESSURE  RECORDS 

The  value  of  graphic  records  is  sufficiently  obvious  to-day 
to  need  no  argument.  We  should  know  little  of  the  character- 
istic temperature  curve  of  typhoid  fever,  if  our  idea  of  it  were 
obtained  by  reading  a  long  column  of  figures.  The  course  of 
the  blood-pressure  is  equally  easy  to  chart,  and  the  curve  thus 
obtained  tells  at  a  glance  what  long  study  of  the  numerical 
readings  would  probably  fail  to  convey.  In  acute  disease,  or 
during  operation,  systolic  pressure  and  pulse-rate  should  be 
charted  at  regular  intervals.  In  more  chronic  cases  a  morn- 
ing and  evening  record  will  answer;  but,  in  cases  of  Bright's 
where  uraemia  is  feared,  frequent  observations  are  quite  as 
essential  as  the  temperature  record  in  a  case  of  fever.  Blood- 
pressure  charts  were  first  introduced  by  Gushing  in  his  opera- 
tive work.  One  of  the  most  helpful  additions  to  them  is  Cook 
and  Briggs's  use  of  a  red  line  for  the  pressure,  a  black  one  for 
the  pulse.  The  spacing  in  their  charts,  however,  never  seemed 
easy  to  follow.  I  have  searched  for  a  suitable  ruhng  among 
the  engineers'  papers,  but  have  failed  to  find  it.  In  conse- 
quence I  have  worked  out  a  chart  for  my  own  use.  Instead 
of  adopting  arbitrary  ruling,  which  may  modify  the  curve,  I 
have  made  0.5  mm.  =  1  mm.,  the  scale  of  the  U-tube  ma- 
nometer.    In  consequence,  the  height  of  the  curve  above  the 

^  Hayaski,  T.  Vergleicheiide  Blutdruckmessungen  an  Gesunden  und 
Kranken  mit  den  Apparaten  von  Gartner,  Riva-Rocci  und  Frey.  Inaug.  Dis- 
sert., Erlangen..     1901,  December, 


102       THE   MODERN   SPHYGMOMANOMETERS 

zero  line  represents  the  absolute  pressure,  on  the  same  scale  as 
a  tracing  from  a  recording  manometer  in  the  physiological 
laboratory.  Each  50  mm.  is  a  double  line,  and  the  100  and 
150  mm.  lines  are  treble  thickness.  Between  these,  the  normal 
systolic  blood-pressure  will  usually  be  found.  A  single  normal 
line,  such  as  Cook  and  Briggs  adopt,  does  violence  to  the  facts, 
for  reasons  which  will  appear  in  the  next  chapter.  For  a 
similar  reason  I  have  been  unwilling  to  couple  any  particular 
pulse-rate  and  tension.  In  my  chart  there  is  but  one  set  of 
figures,  so  that  the  absolute  pulse-rate  can  never  be  confused 
with  the  sphygmomanometer  reading.  To  assist  the  eye,  the 
figures  are  at  both  ends  of  the  chart.  The  vertical  rulings  are 
5  and  10  mm.,  so  arranged  that  either  twice  a  day,  or  every 
four,  or  every  three  hours,  records  may  be  kept  equally  well. 
For  convenience  in  the  operating  room  these  charts  are  padded 
in  blocks  of  fifty,  and  a  double-ended  pencil  is  used,  marking 
the  pressure  in  red,  the  pulse  in  blue.  Where  diastohc  pres- 
sure is  kept,  a  dotted  red  line  indicates  it,  and  a  vertical  dotted 
red  fine,  connecting  systolic  and  diastohc,  represents  the  pulse- 
pressure.  The  respiration  may  also  be  recorded  by  a  dotted 
black  or  blue  line,  an  advantage  in  some  cases. 

One  of  these  charts  in  full  size,  from  a  case  of  lobar  pneu- 
monia at  City  Hospital,  is  shown  in  Fig.  33.  They  are  made 
for  me  by  Mr,  George  W.  Buskirk,  Thirty-fourth  Street  and 
Sixth  Avenue,  New  York.  Having  met  so  much  difficulty  in 
finding  a  convenient  ruled  paper  for  blood-pressure  records,  I 
have  asked  Mr.  Buskirk  to  keep  some  of  these  charts  on  hand, 
in  case  they  should  be  desired  by  others. 

8.    PRACTICAL  SUGGESTIONS 

A.  The  choice  of  a  sphygmomanometer. — The  construction  .of 
an  accurate  instrument  for  the  measurement  of  blood-pressure 
at  the  bedside  is  attended  by  many  difficulties.  The  most 
troublesome  of  these  is  to  combine  simplicity  and  portabihty 
with  exactness.  As  a  consequence,  the  ideal  clinical  sphyg- 
momanometer has  not  yet  been  devised.  It  must  comply  with 
the  following  requirements : 

1.  The  manometer  must  be  of  such  construction  as  to  give 
permanently   exact  readings.     No  metal  manometer  yet  in- 


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PRACTICAL   SUGGESTIONS  103 

vented   remains   accurate,    hence   this   means   the    use    of    a 
properly  graduated  mercury  one. 

2.  The  compressing  armlet  must  have  a  width  of  at  least 
12  cm. 

3.  The  connections  must  be  of  practically  non-distensible 
tubing. 

4.  It  must  measure  both  systolic  and  diastolic  pres- 
sures. 

5.  Its  application  must  be  simple  and  require  not  more  than 
two  or  three  minutes. 

G.  It  must  be  at  once  substantial,  light,  and  compact,  so 
that  it  may  be  easily  and  safely  carried. 

7.  It  should  not  be  too  costly. 

When  we  test  the  existing  forms  of  apparatus  by  these 
standards,  we  find  none  which  are  not  lacking  in  some  respect. 
The  only  instrument  which  can  be  recommended  for  experi- 
ments, which  demand  exact  measurements  of  small  differences 
in  both  systolic  and  diastolic  pressures,  is  Erlanger's.  Unfor- 
tunately it  is  bulky,  requires  some  time  and  care  for  its  use, 
and  is  rather  costly.  One  must  be  somewhat  acquainted  with 
physiological  technique  to  handle  it.  For  office  use,  and  for 
research,  I  consider  it  admirable. 

For  ordinary  clinical,  as  opposed  to  careful  experimental 
work,  Stanton's  sphygmomanometer  and  the  author's  are  quite 
accurate  enough.  The  estimation  of  diastolic  pressure  is  only 
necessary  in  certain  questions  of  diagnosis.  For  routine  use, 
systolic  pressure  alone  is  necessary.  This  can  be  obtained 
with  substantial  accuracy  by  any  instrument  using  the  wide 
cuff.  The  only  apparatus,  except  the  two  mentioned,  which 
can  be  carried  about  on  one's  daily  rounds,  is  Cook's.  This 
cannot  be  relied  on  for  diagnostic  information  on  account  of 
its  narrow  armlet.  Where  absolute  values  are  unnecessary, 
and  it  is  only  desired  to  follow  the  changes  in  blood-pressure, 
in  an  attack  of  acute  disease,  or  a  surgical  operation,  it  is  per- 
fectly adequate.  The  small  cost  is  a  great  recommendation. 
Gartner's  tonometer,  though  much  used  to-day,  I  think  must 
give  place  to  methods  employing  the  more  satisfactory  criterion 
of  the  return  of  the  pulse. 

B.  Minor  details. — To  fill  a  manometer  with  mercury,  use  a 
medicine  dropper.     If  the  tube-calibre  is  small,  the  drops  of 


104       THE   MODERN   SPHYGMOMANOMETERS 

mercury  may  fail  to  go  down.  A  fine  wire  run  down  the  tube 
will  send  the  mercury  to  the  bottom  at  once. 

Never  make  a  reading  with  a  broken  mercury  column. 
Either  shake  it  together  gently,  or  blow  it  up  and  down  with 
the  inflator,  until  the  air-bubble  is  forced  out. 

If  your  sphygmomanometer  will  not  hold  the  pressure,  ex- 
amine all  the  joints  for  the  leak.  If  not  found,  and  the  armlet 
is  air-tight,  there  is  probably  a  pinhc^le  somewhere  in  the 
tubing.  If  it  is  not  possible  to  get  pulsation  enough  in  the 
sphygmomanometer  to  estimate  diastolic  pressure,  readjust 
the  armlet  more  snugly  before  abandoning  the  attempt  to 
measure  it. 

Never  attempt  determinations  where  there  is  oedema,  much 
muscular  twitching,  or  rigidity. 

Practise  using  your  sphj'gmomanometer  on  some  normal 
people  until  you  are  sure  of  the  method,  and  know  a  little  of 
the  variations  of  blood-i3ressure  in  health,  before  putting  confi- 
dence in  your  results  on  i3atients.  Following  the  effect  of  1/1 00 
gr.  of  nitroglycerin  for  half  an  hour,  is  an  excellent  way  of 
acquiring  familiarity  with  the  instrument  at  different  pressures. 
Making  a  diurnal  chart  is  another  good  practical  exercise. 

In  all  readings  for  clinical  purposes,  have  the  patient  abso- 
lutely at  rest.  In  comparative  readings  on  the  same  patient, 
the  position  must  be  the  same,  sitting  or  lying,  with  the  arm 
at  the  level  of  the  heart.  In  daily  observations,  the  hour 
should  be  as  nearly  as  possible  the  same. 


PART   III  -CLINICAL 


CHAPTER  V 

BLOOD-PRESSURE   IN  THE   NORMAL  MAN 

1.  General  considerations. 

2.  Blood-pressure  in  different  individuals. 

A.  Normal  limits  and  influence  of  age,  sex  and  occupa- 

tion. 

B.  Influence  of  size  and  temperament. 

3.  Blood-pressure  variations  in  the  same  individual. 

A.  The  periodic  variations. 

B.  The  diurnal  variations. 
C  Influence  of  posture. 

a.  Influence  of  unaccustomed  rest. 

D.  Influence  of  sleep. 

E.  Influence  of  meals. 

F.  Influence  of  alcohol  and  tobacco. 

G.  Influence  of  psychical  states. 
H.  Influence  of  muscular  exertion. 

I.  Influence  of  external  temperature  and  baths. 

J.  Influence  of  atmospheric  pressure. 

K.  Influence  of  menstruation. 

L.  Summary. 

Literature. 

105 


CHAPTER  V 

BLOOD-PRESSURE   IN  THE  NORMAL  MAN 

1.    GENERAL  CONSIDERATIONS 

In  the  human  being,  as  in  the  experimental  animal,  the 
blood-pressure  at  a  given  moment  depends  upon  the  interplay 
of  four  factors.  The  tv/o  predominant  ones,  cardiac  energy 
and  peripheral  resistance,  are  to  a  high  degree  variable,  but 
at  the  same  time  closely  correlated  through  the  vaso-motor 
and  cardiac  centres  in  the  medulla  oblongata.  With  such 
central  control  there  is  no  a  priori  reason  why  mean  aortic 
pressure  might  not  be  maintained  at  a  practically  constant 
level,  as  is  the  body  temperature,  and  still  leave  ample  scope 
for  the  adaptation  of  blood-supply  which  changing  local  con- 
ditions demand.  Nevertheless,  arterial  pressure  is  no  such 
constant.  Its  fluctuations  greatly  exceed  those  of  the  temper- 
ature under  normal  conditions,  though  the  latter  is  less  abso- 
lute than  many  persons  suppose.  Blood-pressure,  both  in 
health  and  disease,  is  more  comparable  to  the  rate  of  the  heart 
or  the  frequency  of  respiration.  Like  them  it  has  distinct 
normal  upper  and  lower  limits,  between  which  it  varies  from 
person  to  person,  and  in  the  same  individual  from  moment  to 
moment.  Like  them  also,  it  has  wide  and  less  defined  hmits, 
which  it  may  approach  under  pathological  conditions.  To  in- 
terpret rightly  the  blood-pressure  in  disease  we  must  first 
study  its  course  in  health,  under  the  influence  of  those  changes 
in  the  individual  and  his  environment  which  we  class  as 
physiological. 

The  data  for  tins  have  been  obtained  for  the  most  i:>art  with  the  Eiva- 
Eocci  type  of  apparatus  and  a  5  cm.  armlet,  or  the  Gartner  tonometer. 
In  all  cases  the  instrument,  width  of  comisressing  surface,  etc.,  will  be 
given,  using  the  abbreviations  to  be  found  in  the  front  of  the  book.  For 
a  comparison  of  the  results  of  the  various  types  of  sphygmomanometer  see 
Chapter  IV,  section  6.  In  no  case  will  figures  derived  from  the  v.  Basch 
or  similar  form  be  used  in  the  discussion  of  absolute  values,  but  only 

107 


108    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

where  comparative  readings  in  the  same  individual  are  involved,  and  here 
with  considerable  scrutiny.  The  collation  of  figures  relating  to  blood- 
pressure  will  be  most  difficult  until  the  12  cm.  armlet  has  been  univer- 
sally adopted.  In  the  meantime  it  is  impei-ative  that  no  results  be  re- 
l^orted  without  details  as  to  method  and  width  of  cuff  used,  and  circum- 
ference of  arm.  In  every  case  systolic  pressure  is  to  be  understood  unless 
the  contrary  is  specifically  stated. 

2.    BLOOD-PRESSURE   IN   DIFFERENT  INDIVIDUALS 

A.    Normal  Limits  and  Influence  of  Age,  Sex  and  Occupation. 

■ — In  young  adults  there  can  be  little  question  that  'JO  mm. 
(R.  R.),  80  mm.  (G),  represents  the  lowest  systolic  blood-pres- 
sure that  can  be  considered  normal.  The  upper  boundary  is 
more  dubious,  because  the  errors  involved  in  the  method, 
especially  those  inherent  in  the  narrow  armlet,  are  on  the  side 
of  overestimation,  and  it  is  hard  to  eliminate  the  possibility  of 
causes  for  pathological  high  tension.  For  practical  purposes, 
the  greatest  height  to  which  systolic  pressure  may  rise  under 
purely  physiological  conditions  is  of  no  interest,  though  it 
might  satisfy  a  harmless  curiosity.  Avoiding  all  causes,  psy- 
chical and  physical,  for  an  increased  blood-pressure,  160  mm. 
(R.  R.  5  cm.  and  G.)  is  the  usually  accepted  upper  limit. 
With  the  12  cm.  cuff  I  think  145  mm.  will  prove  nearer  the 
absolute  value.  In  more  than  200  determinations,  I  have  only 
once  or  twice  seen  it  exceeded  by  a  few  mm.,  except  where 
cause  for  hypertension  existed.  In  the  great  majority  of 
young  males  100  to  130  mm.  will  be  found.  Females  tend  to 
have  a  systolic  pressure  lower  by  perhaps  10  mm.,  but  with 
the  same  general  limits.  The  larger  differences  sometimes 
found  have  probably  been  due  to  the  smaller  female  arm. 

In  children  under  two  years  the  pressures  are  undoubtedly 
lower.  According  to  Cook  and  Briggs,  75  to  90  mm.  are  the 
usual  figures.  In  older  children  the  values  are  the  same  as 
the  lower  ones  found  for  adults,  and  the  limits  of  variation 
are  smaller.  These  data  have  much  more  absolute  value  than 
our  present  ones  for  adults,  for  two  reasons.  In  children  there 
is  little  likelihood  of  errors  due  to  the  size  of  the  arm ;  and,  in 
the  second  place,  beginning  cardio-vascular  change  can  be 
practically  excluded.  When  we  come  to  the  other  extreme  of 
life,  both  these  causes  of  abnormally  high  readings  come  into 
prominence.     Obesity  is  far  more  common  after  middle  age, 


BLOOD-PRESSURE   IN   INDIVIDUALS  109 

and  changes  in  the  small  vessels  may  give  no  other  evidence 
of  their  onset  than  an  increased  arterial  pressure.  For  these 
reasons  I  think  we  must  be  very  cautious  in  assuming  that  the 
higher  pressure  so  commonly  found  in  elderly  people  is  really 
a  normal  phenomenon;  certainly  one  finds  moderate  figures 
even  in  the  aged.  In  the  routine  examination  of  many  hun- 
dred cases  during  the  last  three  years,  I  have  never  seen  a 
pressure  above  180  mm.  (R.  R.  5  cm.)  in  a  normal  person,  and 
seldom  one  above  IGO  mm.  Gumprecht  puts  200  mm.  as  the 
upper  limit  in  old  people;  Hensen,  170  mm.  These  figures,  of 
course,  hold  good  only  during  physical  and  mental  rest.  With 
the  broad  cuff  they  should  be  20  to  30  mm.  lower.  If  we  ask 
the  usual  values,  not  the  possible  ones,  w^e  find  that,  while  in 
childhood  the  blood-pressure  is  most  frequently  at  its  lower 
normal  levels,  after  fifty  the  average  is  considerably  above 
that  of  early  maturity.  One  expects  140  to  IGO  mm.  (R.  R. 
5  cm.),  130  to  145  mm.  (12  cm.). 

The  cause  of  this  rise  of  blood-pressure  in  later  life  has  been 
variously  explained  by  narrowing  of  the  arterioles  or  of  the 
capillaries,  increased  viscosity  of  the  blood,  and  so  on.  At  least 
we  may  feel  justified  in  assuming  that  it  is  due  to  increasing 
peripheral  resistance,  whatever  be  the  more  remote  causes.  It 
manifests  itself  also  in  a  more  sudden  and  marked  reaction  than 
follows  in  the  young,  when  influences  which  increase  pressure 
come  into  play.     This  we  shall  see  especially  under  exertion. 

The  influence  of  occupation  on  blood-pressure  has  been  little 
studied,  but  Gumprecht  found,  in  men  accustomed  to  hard 
manual  labor,  figures  similar  to  those  which  obtain  in  old  age. 
Here  again  the  greater  muscular  development  and  the  fre- 
quency of  vascular  disease,  in  the  laboring  classes,  make  me 
accept  his  results  conditionally  only. 

For  the  diastolic  pressure  few  figures  can  be  found  in  the 
literature.  On  the  basis  of  several  hundred  readings  in  about 
two  hundred  cases,  besides  a  large  number  of  approximations 
by  my  former  method,  I  should  place  the  normal  at  25  to  40 
mm.  below  the  systolic  pressure  in  the  same  person.  This 
holds  good  only  during  rest,  for  posture,  exertion,  etc.,  affect 
the  two  pressures  unequally.  On  the  same  basis,  not  as  yet  a 
perfectly  adequate  one,  the  normal  limits  of  diastolic  pressure 
would  be  between  G5  and  110  mm.     The  diastolic  pressure 


no    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

tends  to  vary  less  than  the  systolic  under  most  of  the  condi- 
tions which  increase  tension,  especially  the  pathological  ones. 
It  is  therefore  a  less  satisfactory  guide  when  taken  by  itself. 
Taken  in  connection  with  systolic  pressure  it  is  most  valuable. 
Erlanger  calls  the  difference  between  the  two  the  pulse-pres- 
sure. He  and  Hooker  have  shown  that,  under  perfectly  nor- 
mal conditions,  the  product  of  pulse-pressure  by  pulse-rate  tends 
to  remain  constant.  This  is  probably  a  more  accurate  state- 
ment than  Marey's,  that  blood-pressure  and  pulse  have  an  in- 
verse relation  to  one  another. 

RivA-Rocci,  5  CM.  Armlet. 


Highest. 

Lowest. 

Average. 

Cook  and  Briggs : 

Children  up  to  two  years. 
Children  after  two  years. . 
Young  adult  males,  about 
Women 

75-  90  mm. 
90-110    " 

130 
10-  15     " 

lower. 

Gumprecht : 

Children 

90-110     " 
120 
140 
160-200     " 

Women 

Men 

Laborers  and  aged  men.,  i 

Hayaski : 

108  healthy  children  (9-14 
years) 

141  mm. 

180    " 
170    " 

150    " 

(next  135    "   ) 

158    " 
160    " 

102  mm. 

96    " 
100    " 

80    " 

105    " 
105    " 

118      mm. 

58   men   below   sixty  (ex- 
cluding  some    cases   of 
disease  not  excluded  by 
him) 

132        " 

Women 

128 

Hen  sen  : 
25  children 

116 

25  healthy  laborers  (17-30 
years) 

137 

30  healthy  women 

132 

Thayer : 
276    healthy    individuals 
arranged  by  decades. 

37  cases    1-10  years 

87  eases  10-20      "    

89  cases  20-30      "    

37  cases  30-40      "    

20  cases  40-50      "    

5  cases  50-60      "    

1  case    60-70      "    

104.6  " 

128.7  " 
136.9     " 

140.8  " 
142.2    " 
154.8    " 
180 

BLOOD-PRESSURE   IN   INDIVIDUALS 


111 


Gartner's  Tonometer,  1.5  cm.  Ring. 


Doleschal : 
100  persons. 


Gartner 

Grebner  und  Griinbaum. . 

Hayaski : 

108  healthy  children. . . 
58   men   below   sixty  (see 

above) 

Women 


Jackson : 

Young  men,  upper  limit. . 
Old  people,  upper  limit. . . 

Jellinek : 

532  healthy  soldiers 

Great  majority  between . . 

Kapsamer 


Schiile : 

Normal  limits. . . . 
One-half  his  cases. 

Shaw: 
45  children 


Weiss : 

Men,  normal  limits 

Women,  normal  limits. 


105-180  mm. 
110-135  " 


140-150  " 
175 


100-160 


80-130 
100-110 


90-120 
80-100 


Highest. 


120  mm. 

160     " 
145     " 


185 


Lowest. 


85  ram 

80    " 
80    " 


80    " 


Ayerage. 


120  mm. 


97 

111 
106 


120-130    " 


90-100    " 


Hill  and  Barnard. 


Highest. 

Lowest. 

Average. 

Carter : 
Males 

(Sitting) 
(Sitting) 

116mm. 

Females 

Hill 

113     " 
120-125     " 

Jarotzny : 

Adults 

110-130    " 

POTAIN. 

Potain,  with  his  instruments,  considers  170  mm.  the  average  pressure  for 
adults;  140-210  mm.  the  normal  limits. 

V.  Basch. 
V.  Basch  makes  110-140  mm.  the  normal  variation.     150  mm.  he  considers 
hypertension. 


112    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

From  the  systolic  and  diastolic  pressure  the  mean  pressure 
can  be  calculated  with  considerable  accuracy  by  taking  their 
arithmetical  mean,  as  Howell  and  Brush  demonstrated  (see 
page  34).  Since  the  form  of  the  pulse-curve  is  always  a  tri- 
angle, with  the  apex  upwards,  I  feel  convinced  that  the  abso- 
lute mean  pressure,  which  could  only  be  calculated  with  some 
difficulty,  must  be  nearer  the  diastolic  than  the  systolic  level. 
However,  the  average  of  the  two  is  quite  near  enough  for 
practical  purposes. 

The  most  trustworthy  figures  for  normal  human  blood- 
pressure  are  given  on  pages  110  and  111. 

B.  Influence  of  Size  and  Temperament. — Greater  size  and 
body-weight  have  been  said  l)y  many  writers  to  be  attended 
by  higher  blood-pressure.  Until  this  connection  has  been  de- 
monstrated with  the  12  cm.  armlet,  it  seems  quite  probable 
that  such  persons  have  given  erroneously  high  values. 

Temperament  seems  to  have  a  real  influence,  from  the  fact 
that  the  more  excitable  and  neurotic  individuals  show  a  greater 
rise  in  pressure  than  the  phlegmatic,  from  the  same  psychical 
cause.  The  daily  pressure-curve  of  such  persons  will  have  a 
wider  range,  and  single  measurements  of  blood-pressure  will 
more  often  be  unduly  influenced  by  excitement  or  apprehen- 
sion. With  this  nervous  tendency  one  must  reckon  in  the  use 
of  the  sphygmomanometer  for  diagnostic  purposes. 

3.    BLOOD-PRESSURE    VARIATIONS    IN    THE    SAME 

INDIVIDUAL 

A.  The  Periodic  Variations. — These  are  evident  in  the  human 
being  as  in  the  animal.  The  respiratory  and  the  Traube-Hering 
waves,  and  the  other  less  rhythmical  but  apparently  spontane- 
ous fluctuations  in  mean  blood-pressure  (see  page  35),  must  be 
in  mind  during  every  clinical  experiment.  The  respiratorj?^ 
waves  are  usually  negligible  during  quiet  breathing,  though  I 
have  been  able  to  measure  a  10  mm.  rise  in  pressure  during 
expiration,  in  some  people.  In  experiments  on  the  effect  of 
exertion,  when  measurements  are  made  during  deep  labored 
breathing,  they  will  be  very  evident.  Especially  must  it  be 
remembered,  in  comi)aring  the  effect  of  exercise  and  similar 
procedures  on  the  blood-pressuro,  when  investigated  with  dif- 


VARIATIONS   IN   THE   SAME   INDIVIDUAL    113 

ferent  instruments,  that  neither  the  respiratory  nor  Traube- 
Hering  curves  affect  systolic  and  diastolic  pressure  equally. 
In  both  cases,  with  the  rise  in  mean  pressure  there  is  an  in- 
crease in  the  size  of  the  pulse- wave.  This  can  be  seen  beauti- 
fully in  the  curves  reproduced  by  Mosso  (Fig.  34).  It  predi- 
cates a  greater  effect  on  systolic  pressure  than  on  diastolic,  and 
a  consequent  divergence  in  results  between  the  two  types  of 
clinical  instruments.  Exact  figures  for  the  possible  pressure 
variations  due  to  these  causes  are  hard  to  give,  but  their  extent 
in  animals,  combined  with  my  observations  on  the  changes 
noted  in  patients  from  moment  to  moment,  lead  me  to  place 
30  mm.  Hg.  as  the  probable  maximum  rise  which  may  be 


Fig.   34. — Periodic   fluctuations  in   the  tracing   of   blood-peessuee  taken  from 
Dr.  Colombo  (while  at  rest).    (Mosso's  sphygra.) 

(From  Mosso,  Arch.  Ital.  de  Biol.,  1895,  vol.  xxiii,  p.  192,  Fig.  7.) 

attributed  to  them.  One  sees  these  larger  fluctuations  mainly 
in  patients  with  hypertension.  Ordinarily,  5  to  10  mm.  would 
be  a  liberal  estimate. 

A  due  appreciation  of  these  facts  makes  some  of  the  dis- 
crepancies in  the  findings  of  different  observers  intelligible.  I 
do  not  quite  agree  with  Hensen  that,  in  blood-pressure  experi- 
ments, no  conclusions  must  be  drawn  from  changes  of  10  or 
20  mm.  Where  a  chart  of  the  pressure,  at  intervals  of  a  few 
minutes,  is  kept  for  a  considerable  period  before  and  after  the 
procedure  to  be  investigated,  small  differences  can  be  accorded 
distinct  value.  This  is  especially  true  if  each  figure  represents 
the  average  of  two  or  three  successive  readings. 

B.  The  Diurnal  Variations. — A  record  of  blood-pressure  taken 

at  frequent  intervals  throughout  the  twenty -four  hours  shows 
9 


114    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

deviations  from  the  average  level  more  striking  than  those  we 
have  already  considered,  and  of  too  great  extent  and  too  long 
duration  to  be  explained  by  them.     Such  a  chart  is  shown  in 


T^l.^i- 

A.M.              T?n.                           /V.IM.I 

Blood  Pressure. 
Pulse  Rate. 

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Fib.  35. — Diuknal  blood-pkessup.e  ciiaut  of  a  healtuy  man. 
(Author's  sphygin.,  12  cm.) 

Fig.  35.  E\'idently  it  is  a  composite  record  of  the  effect  of 
various  physical  and  mental  states  on  the  blood-pressure.  It 
would  differ  from  individual  to  individual,  and  somewhat  from 
day  to  day.  The  total  diurnal  variation  from  all  causes  proba- 
bly seldom  exceeds  60  mm.  Hg.  Such  extreme  fluctuations 
have  not  come  within  my  experience.  Goldwater,  and  Weiss 
(G.)  picture  them.  Besides  the  more  obvious  causes  for  fluc- 
tuation, which  we  shall  consider  separately,  there  are  unques- 
tionable periodic  rises  and  falls  in  blood-pressure  at  different 
hours  of  the  day,  entirely  unassociated  with  changes  in  exter- 
nal condition,  Colombo  has  studied  these  especially,  and  gives 
a  table  and  chart  of  diastolic  pressures,  taken  with  Mosso's 


VARIATIONS   IN   THE   SAME   INDIVIDUAL     115 

instrument  at  half -hour  intervals  throughout  the  twenty-four, 
which  shows  fluctuation  between  Go  and  100  mm.  (Fig.  30). 

The  supposed  periodic  afternoon  rise  in  pressure  of  certain  observers 
(Zadek,  Hensen,  Jellinek)  is  not  constant,  and  can  probably  be  attributed 
to  psychical  activity,  as  Goldwater  suggests. 

We  shall  now  take  up  the  chief  influences  which  affect 
blood-pressure  in  more  detail. 

C.  Influence  of  Posture.— This  must  not  be  confused  with  the 
effect  of  gravity  (see  page  59),  which  should  be  eliminated  by 
making  all  determinations  at  the  level  of  the  heart.  The  results 
of  concomitant  physical  and  mental  effort  must  also  be  allowed 
to  pass  away  before  judging  the  influence  of  bodily  posture. 


mm.Hg.lOO 
90 
80 

70 
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I'.M.     1      2     3      4      5      6     7      8      9     10    11    12     1      2     3      4      5      6     7      8      9     10     U    12     1 

A.M.                                                                                                     E.M. 

Fig.    36. — Diurnal    variations    in    diastolic    pressure,   the    influence    of    meals 

BEING    EXCLUDED.       (MoSSO's    SphygUl.) 

The  wide  spacing  of  this  chart  exafrgerates  the  chancres  depicted.     (Froni  Colombo, 
Arch.  Hal  de  Biol.,  1899,  vol.  xxxi,  p.  368.) 


With  such  possibilities  of  error,  it  is  not  surprising  that  differ- 
ence of  opinion  exists,  especially  since  the  rise  of  pressure  due 
to  change  of  position  is  so  small  as  to  fall  well  within  the  limits 
of  spontaneous  periodic  variation.     The  weight  of  e^ddence 


116    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

seems  to  point  toward  the  recumbent  posture  as  conducive  to 
the  lowest  pressure,  standing  and  sitting  being  alike  in  raising 
both  systoHc  and  diastohc  pressures  5  to  10  mm. 

Ekgren  in  300  cases  found  the  pressure  averaged  5  mm.  (R.  R.)  lower 
in  the  horizontal  position.  Cook  and  Briggs  give  5  to  10  mm.  (R.  R.)  as 
the  usual  difference:  Gartner,  and  Goldwater  15  mm.  (G)  :  Hill,  about  10 
mm.  (H.  &  B.) :  Brush  and  Fayerweather,  10  mm.  (Mosso).  Henson,  how- 
ever, thinks  pressure  lowest  when  standing,  and  quotes  Friedmann  and 
Schapiro  on  this  side,  as  assuming  a  fall  of  10  to  15  mm.  on  standing. 
V.  Recklinghaiisen  came  to  the  same  conclusion,  but  aj^parently  from  a 
single  experiment  only,  and  in  that  the  pressure  when  lying  without  a 
pillow  was  15  mm.  lower  than  lying  or  sitting,  6  mm.  below  that  on  stand- 
ing. Karrenstein's  60  determinations  with  the  tonometer  showed  an  aver- 
age fall  of  6.7  per  cent,  on  lying,  3.7  per  cent,  on  standing,  as  comiiared 
with  sitting.  I  have  usually  found  a  slight  fall  on  lying  down,  in  normal 
cases. 

The  most  convincing  evidence  on  this  subject  is  found  in 
the  recent  work  of  Erlanger  and  Hooker.  They  found  the 
pressures  about  the  same  sitting  or  lying,  but  on  standing, 
diastolic  pressure  rose  much  more  than  systolic,  the  pulse- 
pressure  variation  being  diminished.  Comparison  with  the 
V.  Kries  tachy graph,  which  showed  the  greatest  acceleration 
of  blood-fiow  per  heart-beat  in  the  recumbent  posture,  con- 
firmed their  observations. 

Evidently  the  postural  variations  of  systolic  pressure  are 
insignificant.  The  main  deduction  to  be  made  from  the  some- 
what conflicting  testimony  is,  to  make  all  comparative  tests  in 
the  same  position,  preferably  the  horizontal  one. 

a.  Influence  of  Unaccustomed  Rest. — Under  this  heading  we  must 
allude  to  Gumprccht's  ol)8ervations  on  the  effect  of  unaccustomed  rest  on 
blood-pressure.  He  found  that  laboring  men  with  pres.sures  between 
160  to  200  mm.  (R.  R.  5  cm.)  on  entrance  to  the  hospital,  showed  a  con- 
siderable fall  after  a  few  days  in  bed.  Hensen  denies  any  effect  of  this 
kind.  Ho  calls  attention  to  the  higher  reading  usual  on  the  first  day  in  a 
hospital,  which  he  considers  due  to  excitement. 

D.  Influence  of  Sleep. — Unc questionably  pressure  is  lowest 
during  the  first  hours  of  natural  sleep,  rising  slowly  toward  the 
time  of  waking.  Whether  the  fall  in  pressure  stands  in  any 
causal  relation  to  the  sleep,  or  whether  both  must  be  considered 
effects  of  a  more  remote  cause,  cannot  bo  statiMb  Tli<^  prompt 
hypnotic  action  of  crythrol  tetranitrate,  a  drug  causing  vaso- 


VARIATIONS   IN   THE   SAME   INDIVIDUAL     117 

dilatation  only,  in  the  cases  of  insomnia  with  high  tension 
studied  by  Bruce,  is  certainly  suggestive.  The  effect  of  posture, 
and  the  absence  of  all  psychical  influences  which  raise  pres- 
sure, seem  adequate  to  explain  the  normal  fall,  but  not  the 
subsequent  gradual  rise. 

Brush  and  Fayerweatlier  found  that  diastolic  pressure  fell  during  the 
first  few  hours  of  normal  sleep,  which  corresi^onds  with  the  minimum  pres- 
sure in  Colombo's  chart,  between  11  and  12  p.  m.  Later  the  ijressure  rose 
gradually,  but  not  uniformly,  the  curve  showing  long  waves.  On  awaking, 
the  pressure  was  somewhat  higher  than  before  sleep.  Hill,  however,  did 
not  believe  that  blood-pressure  was  any  lower  during  sleep  than  when  rest- 
ing in  the  recumbent  position.  Kornfeld,  in  his  studies  on  trional,  found 
that  the  fall  in  pressure  after  taking  the  drug  was  much  greater  if  the  hyp- 
notic effect  were  obtained,  than  if  not.  He  attributes  the  whole  action 
to  a  diminished  irritability  of  the  nervous  system. 

E.  Influence  of  Meals. — The  effect  of  the  ingestion  and  diges- 
tion of  food  on  arterial  pressure  is  another  disputed  point,  so 
much  so  that  it  is  wiser  to  suspend  judgment  on  it  until  more 
complete  data  are  available.  Here  again  many  other  factors 
may  enter  in  and  be  the  cause  of  wide  individual  variation. 

Colombo's  charts  show  a  constant  fall  in  diastolic  pressure  up  to  20 
mm.  (Mosso),  after  meals,  absolutely  independent  of  the  time  of  day  at 
which  they  were  eaten.  No  other  work  on  the  subject  has  been  so  care- 
fully performed.  Weiss  found  a  similar  fall.  Gum^jrecht,  on  the  other 
hand,  frequently  found  a  slight  rise  in  systolic  pressure,  up  to  20  mm. 
(E.  E.),  after  the  hearty  meal  of  the  day.  With  the  Gartner  tonometer 
Jellinek  found  in  14  out  of  20  soldiers  a  rise,  no  change  in  4,  and  a  fall 
in  2.  Karrenstein  saw  a  rise  of  10  to  20  mm.  commonly  after  the  principal 
meal,  and  never  failed  to  get  an  elevation  of  10  to  25  mm.  if  much  fluid 
(2  litres  of  beer)  were  drunk.  Sommerfeld  considered  the  midday  meal 
the  cause  of  a  rise,  and  Hayaski  never  missed  it.  A  most  interesting  ob- 
servation of  Cook's  was  the  regular  rise  of  5  to  10  mm.  in  systolic  pressui-e 
in  infants,  following  nursing  from  the  bottle. 

In  my  chart  (Fig.  35)  a  rise  of  5  mm.  in  systolic,  and  a  fall  of  5  mm, 
in  diastolic  pressure,  followed  both  dinner  and  supper. 

Those  who  find  a  lower  pressure  during  digestion  assume 
with  apparent  justice  that  it  is  due  to  vaso-dilatation  in  the 
splanchnic  area.  It  may  be  that  some  individuals  have  accom- 
panying this  an  amount  of  superficial  vaso-constriction  which 
overcompensates  (see  page  24).  Thus  they  would  evince  an 
actually  higher  pressure.     I  am  inclined  to  believe,  however, 


118    BLOOD-PRESSURE   IN   THE   NORMAL  MAN 

that  studies  of  the  pnlse-pressure  variation  will  show  that  sys- 
tolic and  diastolic  pressure  are  unequally  affected  by  the  tak- 
ing of  food,  and  that  the  discordant  observations  quoted  may 
thus  be  harmonized. 

F.  Influence  of  Alcohol  and  Tobacco. — The  enjoyment  of  some 
form  of  alcohoHc  beverage,  and  of  tobacco,  so  commonly  ac- 


AfcrcA  /3. 

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Pulse  Rate 

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FlO.    37. — KiSE   IN   BLOOD-PRESSURK   PRODUCED    BV    TOBACCO. 

(Erlanger\s  sphygni.,  12  cm.) 

Chart  obtained  from  a  healthy  young  man,  sitting  quietly,  who  smoked  a  strong  cigar 

between  (1)  and  (2). 

companies  the  normal  man's  meal,  that  the  influence  of  these 
drugs  on  blood-pressure  may  be  best  discussed  here. 

Alcohol,  contrary  to  the  usual  belief  expressed  in  the  lan- 
guage of  daily  hfe,  is  not  a  stimulant,  at  least  so  far  as  the 
circulation  is  concerned.  The  pharmacologists  agree  that  it 
produces  no  rise  in  blood-pressure  or  in  cardiac  energy  when 
injected  directly  into  a  vein.     On  the  contrary,  if  a  consider- 


VARIATIONS   IN   THE   SAME   INDIVIDUAL     119 

able  dose  be  given,  arterial  pressure  falls  from  weakening  of 
both  vaso-constrictor  centres  and  heart  (see  Cushney).  In 
man  there  seems  no  good  reason  to  doubt  that  its  effect  is  the 
same.  Swientochowski,  Schiile,  and  Wren  and  Oertel  have, 
in  fact,  demonstrated  that  no  elevation  of  systolic  pressure  fol- 
lows its  administration.  Observations  on  the  pulse-pressures 
are  lacking. 

Tobacco,  on  the  other  hand,  or  its  alkaloid  nicotin,  have  a 
powerful  action  on  the  circulation.  Nicotin,  in  less  than  over- 
whelming dose,  produces  an  immense  augmentation  of  blood- 
pressure  in  animals,  due  to  stimulation  of  both  central  and 
peripheral  vaso-constrictor  mechanisms  (Cushney).  Cook  and 
Briggs  have  called  attention  to  the  temporary  elevation  of 
arterial  tension  during  smoking.  They  found  it  most  marked 
when  a  strong  cigar  or  old  pipe  is  used,  and  continuing  an  hour 
or  more  after  the  smoke  is  ended.  This  latter  statement  I 
have  been  unable  to  confirm  (see  Fig.  37). 

G.  Influence  of  Psychical  States. — When  we  come  to  study 
the  effect  of  different  psychical  states  on  blood-pressure,  we 
fortunately  meet  with  more  unanimity  of  opinion.  Excite- 
ment seems  indubitably  the  most  powerful  cause  of  increased 
pressure  in  the  normal  man.  A  heated  argument  may  raise 
the  systolic  pressure  in  a  short  time  as  much  as  40  mm.,  as  is 
shown  in  Goldwater's  diurnal  chart  (G).  The  accompanying 
chart  (Fig.  38)  shows  a  moderate  increase  in  systolic  pressure 
and  pulse-rate,  after  lecturing  an  hour  to  a  large  class,  certainly 
a  considerable  mental  effort,  with  some  excitement.  Diastolic 
pressure  was  much  less  affected.  Especially  striking  is  the 
rapid  fall,  to  below  the  initial  pressure  in  less  than  six  minutes, 
after  the  cessation  of  the  effort. 

Goldwater,  and  Kapsamer  (G),  Gumprecht  (E,  R.),  and  Hill  (H.  &  B.), 
have  recorded  equally  pronounced  changes,  and  every  one  who  uses  a 
sphygmomanometer  may  observe  them.  Anger  is  especially  jDotent  in  its 
effect.  Some  attempt  has  been  made  to  differentiate  the  effects  of  the 
separate  forms  of  cerebral  activity,  perceptive,  volitional,  intellectual,  etc. 
Kiesow  made  a  number  of  experiments  with  Mosso's  sjjhygmomanometer, 
in  which  he  showed  a  distinct  rise  in  diastolic  pressure  with  the  intellectual 
effort  of  a  simple  arithmetical  calculation,  with  mild  fright,  with  disagree- 
able taste  perceptions,  but  not  with  odors.  With  sight  impressions,  even 
when  the  closest  effort  of  attention  was  involved,  he  found  no  influence  on 
the  curve.    Gumprecht  also  found  the  mere  effort  of  attention  usually 


120    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

without  efifect  on  systolic  pressure  {l\.  R.);  sometimes  a  rise  of  5  or  10 
mm.  was  produced.  One  student,  when  he  read  the  manometer  himself, 
always  showed  15  mm.  higher  i:)ressure  than  when  he  did  not.  Even  the 
slighter  emotional  conditions,  such  as  gentle  laughter,  were  enough  to 
cause  a  considerable  increase  (16  mm.  R.  R.).  Pain  has  a  similar  efifect. 
The  explanation  of  these  marked  influences  must  be  sought  in  the  well- 
known    reflex   vaso-constriction    which    follows   stimulation    of    sensory 


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Fia.  38. — KisE  in  blood-pkessuue  produced  by  mental  effort. 
(Erlaiijfer's  sphygiii.,  12  cm.) 

Cliiirt  olitiiincd  iVdiii  I'rof.  ,  who  leoturtHl  t"  ;i  large  class  IVoia  twelve  to  one 

o'clock.     Jieforc  ami  -a^Wx  lecture  lie  sat  ijuii-'tly  in  liis  laboratory. 

Note  the  coinciih^it  rise  in  pulse-rate;  the  greater  rise  in  sy.stolic  than  in  diastolic 
pressure;  the  sul)se(j.uent  lall  in  pressure,  with  decreased  pulse-pressure,  while  the  ruto 
rernainetl  rapid. 


nerves  in  general,  and  of  the  cerebral  cortex  (sec  page  21).  One  is 
tempted  to  think  of  the  dependence  of  the  brain  circulation  \\\}oxv  general 
blood-pressiare  to  meet  its  local  demands,  since  the  brain  vessels  probably 
have  little  vaso-motor  supply,  as  the  possible  cause  of  the  increased  aortic 
pressure  which  accompanies  cerebral  activity. 


VARIATIONS   IN   THE   SAME   INDIVIDUAL     121 

The  meaning  of  these  psychical  influences  for  the  clinician 
is  obvious.  In  all  determinations  of  blood-pressure  they  should 
be  conspicuous  by  their  absence,  and  the  physician  must  sedu- 
lously guard  his  patient  against  undue  interest  in  the  pro- 
cedure itself,  or  fear  of  it,  and  secure  as  complete  mental 
relaxation  as  possible  during  the  measurement. 

H.  Influence  of  Muscular  Exertion. — That  muscular  work 
usually  increases  systolic  blood-pressure  in  man  has  been 
known  since  the  early  investigations  with  the  v.  Basch  sphyg- 


Blooa  PresHUre      Pulse 
ill  nmi.Hs.           Kiite 

200                 100 

160             120 

130             80 

80              W 

10                         20                          30                         40         Jliimtea 

^ 

^^O^ 

^ 

I 

v^-^ 

::^  —  -^    -■"   r      -] 

; 

Fig.  39. — Kise  in  blood-pressuke  pkoduced  by  muscular  exertion. 
(Riva-Kocci's  sphygm.,  5  cm.) 

Chart  obtained  from  a  student  of  twenty-two,  who  performed,  with  both  legs,  88 
kilogrammeters  of  work  a  minute.  At  the  close  of  the  work,  slight  fatigue  of  the  legs, 
and  somewhat  deepened  respiration. 

The  hatched  area  below  indicates  the  duration  of  the  work. 

Note  the  rapid  rise  in  blood-pressure  and  pulse-rate,  maintained  throughout;  and  the 
equally  rapid  return  to  normal.  (From  Masing,  Deutsch.  Arch.  f.  klin.  Med.,  1902, 
vol.  Ixxiv,  p.  283.) 


momanometer.  This,  of  course,  tallies  with  the  results  of 
Tangl  and  Zunst  in  dogs  (see  page  39).  Zadek,  and  Maxim- 
owitch  and  Rieder  found  the  rise  in  pressure  proportional  to 
the  work  done,  reaching  as  much  as  50  mm.  Hg.  with  young 
men  undergoing  severe  exertion,  falling  rapidly  after  its  ces- 
sation, and  becoming  again  normal  within  twenty  to  thirty 
minutes.  Their  results  have  been  verified  by  practically  all 
recent  observers.  Among  the  latter,  Jellinek,  Grebner  and 
Griinbaum,   Kornfeld,   Masing,  and  O.  Moritz   have  investi- 


122    BLOOD-PRESSURE   IN   THE   NORMAL  MAN 

gated  this  question  particularly,  and  have  brought  to  light 
certain  facts  which  require  more  detailed  consideration. 

O.  Moritz,  Masing,  and  Kornfeld,  all  empliasize  the  psychical  factor  in 

muscular  effort.  This  manifests  itself  unmistakably  in  their  experiments. 
The  greater  the  conscious  effort  the  greater  the  rise  in  i^ressure,  and  vice 
versa  ;  so  that  pressure  seems  proportional  rather  to  the  fatigue  produced 
than  to  the  actual  work  done.  Work  performed  with  a  single  leg  raised 
pressure  more  than  the  same  amount  done  by  the  two  legs  alternately, 
and  the  first  performance  more  than  subsequent  ones  (Masing).  Kornfeld 
found  that  the  attempt  to  walk  in  a  straight  line  had  more  effect  than  the 
same  distance  without  any  special  attention.  Moritz  goes  so  far  as  to  state 
that  the  pressure  elevation  during  bodily  work  is  principally  conditioned 
by  psychical  influences.  These  facts  explain  at  once  the  effect  of  practice, 
as  in  athletic  training  for  instance,  which  consists  essentially  in  such  rep- 
etition that  coih'dinations  become  almost  automatic  reflexes,  and  the  vol- 
untary effort  is  reduced  to  a  minimum.  They  also  make  intelligible  the 
few  discordant  observations  in  which  exercise  did  not  raise  pressure,  such 
as  Jellinek's  on  106  soldiers,  in  whom  marching  raised  pressure  in  57,  had 
no  efiect  in  30,  and  was  attended  by  a  slight  fall  in  19  (G).  Here,  appar- 
ently, the  eftbrt  was  insufficient  of  itself  to  affect  49  of  the  men,  and 
other  factors  determined  the  results  found.  The  individual  differences 
reported  by  Schi'ile,  and  Huber,  may  be  similarly  explained. 

The  relative  effect  of  exertion  on  systolic  and  diastolic  i^ressures  has 
been  investigated  by  Masing.  By  a  method  yielding  aj^proximate  values 
only,  he  found  that  both  systolic  and  diastolic  pressure  rise  during  exer- 
tion, but  in  different  degree,  the  diastolic  always  less.  This  is  in  accord 
with  the  well-known  increase  in  iwlse-volume.  One  experiment  of  mine 
with  the  Erlanger  apparatus  (5  cm.  armlet)  showed  the  following  in  a 
healthy  young  man  of  twenty-six  years. 


Sitting 

Ikying 

After  running  up 
three  flights  of 
stairs.   Sitting. 


SYSTOLIC  PEESSURE. 


135  mm.  Hg. 
125  mm.  Ilg. 


175  mm.  Hg.  =  40  mm.  increase 


DIASTOLIC  PRESSURE. 


100  mm.  Hg. 
95  mm.  Hg. 


120  mm.  Hg.  =  20  mm.  increase 


It  follows  then,  that  instruments  measuring  systolic  pressure  will  over- 
estimate, those  giving  diastolic  will  underestimate,  the  effect  of  exertion 
on  mean  aortic  pressure.  Here,  as  elsewhere,  the  determination  of  both 
pressures  would  be  most  valuable  in  throwing  light  on  the  actual  vascular 
changes.  The  indications  afforded  by  the  increased  pulse-volume,  in  the 
present  instance,  point  clearly  to  increased  energy  of  the  heart  as  at  least 
one  factor  in  the  rise  of  pressure,  if  not  the  only  one.     Under  conditions 


VARIATIONS   IN   THE   SAME   INDIVIDUAL     123 


of  too  excessive  work  in  projiortion  to  the  individual's  cardiac  power,  the 
blood -pressure,  after  its  primary  rise,  may  show  a  gradual  fall,  even 
below  the  normal.  With  this  there  are  dyspnoea  and  other  subjective 
symptoms,  and,  according  to  Schott,  and  Larrabee,  acute  dilatation  of  the 
heart.  Here  we  border  on  the  pathological  effects  seen  in  diseased  hearts, 
which  will  be  considered  later.  Masing  has  found  similar  results  from 
moderate  exertion  in  the  aged,  the  i^rimary  rise  of  j^ressure  being  main- 
tained for  only  a  short  time.   In  these  older  men  there  was  also  less  accel- 


FiG.  40. — Influence  of  muscular  exektion  on  blood-pressure  in  the  aged. 
(Eiva-Kocci's  sphygiu.,  5  cm.) 

Chart  obtained  from  a  man  of  sixty-eight,  with  the  same  work  as  the  subject  of 
Fig.  39.  During  the  work  the  pulse  became  quite  irregular  at  times ;  after  seventeen 
minutes,  dyspno3a.  At  the  close  of  the  work,  dyspnrea,  palpitation,  great  fatigue  of 
the  legs. 

Note  the  great  rise  in  blood-pressure  as  compared  with  pulse-rate;  its  fall  during  the 
work ;  the  more  gradual  return  to  normal  at  its  close.     (From  Masing,  loc.  cit.,  p.  286.) 

eration  of  the  heart  than  in  the  young.  Here  again  is  strong  evidence 
that  the  rise  during  physical  work  is  due  to  increased  cardiac  energy. 

Karrenstein  has  just  published  observations  on  74  soldiers  under- 
going rather  protracted  exertion ;  in  one  test,  a  march  of  about  seventy 
minutes'  duration  over  a  considerable  hill ;  in  the  other,  three  hours'  exer- 
cise. The  great  bulk  of  his  men  showed  a  fall,  most  of  those  who  did  not 
having  drunk  considerable  beer.  He  considers  that  in  long-continued 
exertion  a  fall  in  jjressure  is  common.  Since  he  also  noticed  some  increase 
in  heart  dulness  in  many  cases,  this  fall  seems  analogous  to  that  which 
occurs  earlier  in  the  aged  and  those  with  weak  hearts.  One  is  also 
tempted  to  postulate  a  depressor  fall,  as  a  protective  reflex  from  the  heart. 

Finally  it  must  be  remarked,  that  the  curves  of  iDressure  during  exer- 
tion show  irregular  rises  and  falls,  which  are  difficult  of  exi^lanation 
(Grebner  and  Griinbaum,  Masing).  The  most  marked  falls  accompany 
profuse  sweating. 


124     BLOOD-PRESSURE   IN    THE   NORMAL   MAN 

"We  may  summarize  these  facts  as  follows : 

The  rise  in  pressure  during  physical  exertion  is  in  general 
proportional  directly  to  the  amount  of  work  done  and  to  the 
voluntary  effort  required,  the  latter  factor  being  the  more  im- 
portant. The  effect  on  systolic  pressure  is  more  marked,  that 
on  diastolic  less  marked  than  on  mean  pressure. 

The  rise  is  due  to  increased  energy  of  the  heart  (both  rate 
and  pulse- volume),  and,  when  the  demand  exceeds  the  reserve 
force  of  the  heart,  it  will  not  be  maintained.  With  equal  work  it 
is  of  much  shorter  duration  in  the  aged  than  in  the  normal  adult. 

Prolonged  exertion  usually  causes  a  fall  in  pressure. 

I.  Influence  of  External  Temperature  and  Baths. — The  effect 
of  temperature  changes  upon  the  local  circulation  has  long 
been  well  known  and  commonly  used  in  practice.  Cold  pro- 
duces local  vaso-constriction,  which,  if  sufficiently  long  con- 
tinued, eventually  gives  way  to  a  dilatation,  due  to  paralysis  of 
the  vaso-motor  mechanism.  Besides  this,  when  cold  is  applied 
for  a  short  time  and  then  removed,  a  reaction  follows  and  the 
part  becomes  intensely  hypersemic,  a  sign  of  secondary  active 
vaso-dilatation.  Warmth,  on  the  other  hand,  produces  vaso- 
dilatation and  local  hypersemia  from  the  outset,  probably  of  a 
passive  nature ;  that  is,  from  diminished  vaso-constrictor  tone. 

If  the  local  area  thus  subjected  to  changed  temperature 
conditions  be  sufficiently  large,  a  marked  influence  will  be 
exerted  on  the  distribution  of  the  blood  throughout  the  body, 
and,  if  there  be  no  counterbalancing  change  elsewhere,  on  the 
general  blood-pressure.  It  is  just  at  this  point  that  comi)lica- 
tions  arise.  We  have  seen  (see  page  21)  that,  not  only  do 
external  irritations  of  any  kind  produce  reflex  vaso-motor 
effects  in  remote  vascular  areas,  in  that  innervated  by  the 
splanchnic  nerves  especially ;  but  also  that  the  blood-vessels  of 
the  skin  and  those  of  the  abdominal  viscera  frequentlj^  act  in 
antagonism  to  one  another.  For  this  reason  it  is  impossible  to 
predict  that  the  application  of  cold  sufficient  to  constrict  all 
the  superficial  arterioles  will  necessarily  raise  aortic  pressure; 
for  a  reflex  dilatation  of  the  si)lanchnic  vessels  might  more 
than  compensate  for  the  added  resistance.  The  question  must 
evidently  be  approached  experimcntall3^ 

Here  we  at  once  meet  the  tlifHciilty,  that  the  necessary  procedures 
may  be  attended  by  physical  exertion  and  mental  excitement,  with  their 


VARIATIONS   IN  THE  SAME   INDIVIDUAL     125 


concomitant  vascular  effects.  In  almost  all  the  work  upon  the  subject 
these  have  not  been  carefully  enough  eliminated.  In  addition,  much  of 
the  investigation  has  been  with  the  inaccurate  v.  Basch  instrument ;  as, 
for  instance,  Jakob's  work,  which  I  cannot  place  any  reliance  in.  The  Gart- 
ner tonometer,  and  Mosso's  sphygmomanometer  also,  must  be  fallacious 
for  this  purjiose,  because  in- 
fluenced by  the  local  vaso-mo- 
tor  conditions  induced  in  the 
fingers  ;  hence  Jellinek's,  and 
Tschlenofif's  results  cannot  be 
accei^ted.  Edgecombe  and 
Bain  studied  the  question  of 
baths  and  exercise  with  consid- 
erable care,  but  used  Oliver's 
hoemodynamometer.  Their  re- 
sults agree  in  the  main  with 
the  experiments  which  follow, 
and  add  nothing  to  them.  The 
most  careful  investigations  I 
have  been  able  to  find  are  those 
of  Bruck,  and  of  Miiller. 

The  former  studied  the  ef- 
fect of  cold  hydrotherapeutic 
procedures  on  jjersons  with 
mild  neurasthenia,  early  phthi- 
sis, and  other  conditions  in 
which  a  practically  normal  car- 
dio- vascular  state  was  present. 
All  measurements  were  made 
with  the  Eiva-Eocci  apparatus 
(5  cm.),  between  8  and  10  \.  m. 
to  avoid  diurnal  variations,  and 
in  the  recumbent  jjosture.  He 
noted  the  i)ressure,  pulse -rate, 
and  temperature  five  minutes 
before  the  bath  or  douche,  and 
five,  fifteen,  thirty,  and  sixty 
minutes  after.  He  also  used 
great  care  in  observing,  not 
only  the  temperature,  but  also  the  duration  of  the  bath.  In  this  way  he 
found  a  definite  relation  between  the  duration  of  the  cold  and  the  change 
in  pressure,  and  considers  the  divergent  results  of  previous  investigators 
as  due  to  varying  time  or  temperature  employed.  He  found  that  full 
baths  at  80°  C.  gave  a  rise  in  pressure  in  one-half  minute  ;  at  13°  to  16°  C. 
in  one  minute ;  at  20°  to  22°  C.  only  after  two  minutes  or  longer,  a  fall 
occurring  when  the  bath  was  discontinued  sooner.     Ho  could  ascertain 


Minutes 
10       20       30      4(1       50       GO      70        RQ 

iiy:. 

140 
130 
120 
110 
100 

120 
110 
100 
90 

/^ 

V 

a/ 

-A 

\ 

V 

j) 

\ 

s 

; 

^ 

X 

^ 

Water  Bath  at  42.5°C. 

h 

+ 

\ 

/i^ 

7=*- 



^ 

V 

s  — 

K 

■^vC. 

Water  Bath  at  3G.25"c. 

130 
120 
110 
100 
90 
80 

k 

A 

r 

^ 

v 

\ 

..^ 

^ 

.^— ■ 

^ 

;^ 

\ 

/ 

""^ 

^ 

1 

/ 

Water  Bath  at  28.75" C. 

G.     41. — Influence    of    watek    baths     of 

DIFFERENT     TEMPERATURES     ON     BLOOD-PKES- 
SURE  AND    PULSE-RATE  IN  A  HEALTHY   MAN  OF 

TWENTY-SIX.     (Eiva-Eocci's  sphygm.,  15  cm.) 


(From   Mnller,   Dcutsch.    Arch.  f.  klin. 
1902,  vol.  Ixxiv,  Plato  IV.) 


Jled., 


126     BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

no  constant  relation  between  pressure  and  pulse-rate,  or  body  tempera- 
ture.    The  relation  between  duration  and  efiect  was  always  striking. 

Miiller,  using  a  Eiva-Rocci  iustmment  with  15  cm.  armlet,  and  ap- 
parently eveiy  precaution,  came  to  the  following  rather  striking  conclu- 
sions :  1.  "Water  baths  of  a  temiierature  below  33°  to  35°  C.  produce  a  rise 
in  blood-pressure,  with  slowing  of  the  pulse,  throughout  the  whole  dura- 
tion of  the  bath.  The  colder  the  temperature  the  greater  the  rise,  in  the 
same  individual.  2.  Water  baths  from  33°  to  35°,  to  about  40°  C.  (the  so- 
called  indifferent  zone)  produce,  after  a  short  initial  rise,  a  fall  in  pressure 
to  or  below  the  normal,  followed  by  another  rise.  The  behavior  of  the 
pulse  differs  in  this  group ;  below  37°  C.  it  diminishes,  above  it  increases. 
3.  Water  baths  from  40°  C.  uji  i:)roduce  a  rise  in  jjressure,  lasting  during 
the  entire  bath, with  increase  in  imlse-rate.  These  effects  are  very  readily 
seen  in  the  accomi^anying  charts  (Fig.  41).  4.  "With  hot-air  and  steam 
baths  at  50°  C,  the  same  rise  in  pressure  and  pulse-rate  occurred  in  nor- 
mal persons.  With  certain  sick  patients,  however,  in  whom  heart  weak- 
ness probably  existed,  the  rise  in  pressure  soon  gave  way  to  a  fall,  or  the 
pressure  fell  from  the  start.  The  indi^-idual  reaction  to  the  varying  tem- 
peratures employed  was  quite  different  in  amount,  but  the  same  in  kind, 
for  all  the  cases  studied.  The  more  complicated  hydrotherapeutic  ques- 
tions I  will  not  enter  upon,  since  we,  in  this  country,  unfortunately  lack 
the  requisite  technical  knowledge  of  the  subject.  Those  interested  may 
find  a  full  literature  in  Miiller's  i^aper. 

We  may  therefore  conclude  that,  so  far  as  our  present 
knowledge  goes,  baths  at  about  body -temperature  are  without 
marked  effect  on  the  blood-pressure;  that  cold  baths  produce  a 
rise  in  systolic  pressure,  the  extent  of  which,  in  any  given  in- 
di^^dual,  is  greater  the  lower  the  temperature  and  the  longer 
the  period  of  exposure  to  it,  within  limits  which  undoubtedly 
exist,  but  have  not  yet  been  determined ;  that  hot  baths  follow 
the  same  rule,  differing  only  in  that  the  rise  in  systolic  pres- 
sure is  accompanied  by  a  more  rapid  pulse.  Since  the  same 
phenomena  have  been  observed  with  steam  and  hot-air  baths, 
there  seems  no  reason  to  doubt  that  the  efficient  cause  is  the 
change  in  external  temperature.  Of  the  actual  mechanism 
by  which  the  pressure  changes  are  brought  about,  whether  in- 
crease of  peripheral  resistance,  or  of  the  heart's  energy,  or 
both,  I  do  not  think  we  may  form  any  valid  opinion  at  present. 
Determinations  of  systolic  and  diastoHe  pressures  are  much  to 
be  desired  in  this  connection. 

K.  Influence  of  Atmospheric  Pressure. — There  is  little  to  be 
found  on  the  effects  of  atmospheric  pressure  on  arterial  pres- 


VARIATIONS   IN   THE  SAME   INDIVIDUAL     127 

sure  in  the  normal  man,  the  bulk  of  the  observations  being  in 
conditions  of  shock.  Lazarus  and  Schirmunski,  however, 
amplified  their  animal  experiments  (see  page  38),  by  subject- 
ing men  to  a  gradual  reduction  in  atmospheric  pressure  from 
7G0  to  380  mm.  In  all  cases  a  fall  of  25  to  35  mm.  (v.  B.) 
was  obtained,  and  headache,  dizziness,  palpitation,  or  dyspnoea 
appeared  in  varying  combination. 

L.  Influence  of  Menstruation. — I  have  found  but  three  refer- 
ences in  the  literature  to  the  behavior  of  arterial  pressure  dur- 
ing the  menstrual  period,  in  normal  women.  These  do  not 
allow  of  definite  conclusions,  because  they  fail  to  agree  com- 
pletely. We  may  only  say  that  a  diminution  of  tension  may 
be  normal. 

Wiessner  studied  the  question  especially  and  claimed  to  find  a  regular 
fall  of  20  mm.  (R.  R.  5  cm.)  during  menstruation,  tlie  normal  level  being 
restored  three  or  four  days  after  cessation  of  the  flow.  Hensen  could  not 
satisfy  himself  of  any  particular  change.  Rosse,  who  made  measurements 
with  the  tonometer,  in  women  who  showed  no  particular  disturbance 
during  the  j)eriod,  as  a  check  to  his  results  in  hysterical  girls,  noted 
either  a  slight  diminution  of  tension  or  no  variation.  Federn  noted  a  fall 
either  shortly  before,  at,  or  after  the  beginning  of  the  flow,  the  pressure 
rising  gradually  through  the  intermenstrual  period. 

M.  Summary. — This  array  of  facts  regarding  the  variations 
of  blood-pressure  in  the  healthy  man  and  their  numerous 
causes  might,  at  the  first  blush,  lead  one  to  conclude  that, 
where  such  instability  is  normal,  there  can  be  no  firm  ground 
for  the  construction  of  a  standard  by  which  to  gauge  the  ab- 
normal. This  is  certainly  untrue.  Because  the  pulse-rate 
may  reach  120  during  exertion  or  excitement,  the  rapid  pulse 
of  fever  is  no  less  significant ;  nor  is  the  existence  of  a  digestion 
leucocytosis  a  valid  reason  for  considering  inflammatory  leu- 
cocytosis  a  normal  phenomenon.  We  must  know  the  possi- 
bility of  digestion  leucocytosis  that  its  occurrence  may  not 
lead  us  into  an  erroneous  diagnosis.  Similarly  we  must  know 
thoroughly  the  causes  for  changes  in  blood-pressure  during 
health ;  then  we  shall  be  able,  by  excluding  or  taking  account 
of  them,  to  recognize  and  value  the  pathological  indications. 

We  have  seen  that  mental  activity,  and  especially  excite- 
ment, produce  the  greatest  rises  in  pressure.  Exertion  also 
causes  a  rise,  the  amount  depending  on  the  severity  of  the 


128    BLOOD-PRESSURE   IN   THE  NORMAL  MAN 

effort  required.  Mental  and  phj^sical  rest  must  therefore  be 
secured  in  all  clinical  observations.  Excessive  changes  in  ex- 
ternal temperature  should  be  guarded  against.  Since  posture 
may  have  some  influence,  it  is  wise  to  make  all  tests  in  the 
same  position,  either  sitting  or  reclining;  preferably  the  latter, 
because  it  conduces  most  to  the  desired  rest.  The  diurnal 
variations,  including  the  effects  of  eating  and  of  sleep,  must 
be  in  mind.  In  following  cases  from  day  to  day,  especially 
with  reference  to  the  effects  of  treatment  on  the  blood-pres- 
sure, determinations  should  be  made  at  the  same  hours. 
Everj'one  admits  the  importance  of  this  in  studying  the  course 
of  the  temperature  in  disease.  With  the  arterial  pressure  it  is 
not  a  whit  less  important.  Where  experiments,  are  made 
which  occupy  only  minutes  or  hours,  instead  of  days,  it  is 
essential  that  a  record  of  the  pressure  be  made  at  frequent 
intervals  for  some  time  previous,  to  establish  the  normal  level 
and  the  extent  of  the  periodic  variations.  When  this  is  done, 
it  may  be  possible  to  demonstrate  changes  of  small  extent, 
which,  lacking  this  standard  for  comparison,  would  be  con- 
sidered within  the  limits  of  normal  variation. 

Studied  under  such  conditions,  and  they  are  scarcely  more 
rigorous  than  the  simple  taking  of  temperature  requires,  it  is 
surprising  how  constant  the  blood-pressure  may  be.  Day  after 
day  it  may  not  vary  10  mm.  at  a  given  hour.  Hensen  was 
struck  with  this,  and  I  have  found  it  conspicuous  in  measure- 
ments made  on  successive  days  in  ofiice  practice,  where  the 
conditions  do  not  vary.  In  hospital  charts,  where  observa- 
tions are  made  hurriedly,  and  so  many  causes  for  psychical 
irritation  exist,  I  see  more  fluctuation. 

From  individual  to  individual  the  differences  are  more  pro- 
nounced, but  not  more  so  than  the  differences  in  pulse-rate. 
The  vast  majority  of  healthy  adults  will  show  systolic  pres- 
sures of  100  to  130  mm.  (12  cm.  armlet),  110  to  150  mm. 
(5  cm.).  The  diastolic  pressure  will  be  25  to  40  mm.  lower. 
After  middle  life  130  to  145  mm.  (12  cm.)  is  not  uncommon, 
140  to  100  mm.  (5  cm.).  In  childhood  00  to  110  mm.  after  the 
second  year,  75  to  90  mm.  before  it,  make  the  lower  end  of 
the  scale,  with  probably  a  slighter  difference  between  systolic 
and  diastolic  pressures.  With  women  the  })ressure  tends  to  be 
slightly  lower,  more  definitely  so  when  the  5  cm.  armlet  is  used. 


LITERATURE  129 

I  regard  with  suspicion  any  pressure  above  135  mm.  (12 
cm.),  150  mm.  (5  cm.),  in  a  young  person,  145  mm.  (12  cm.), 
or  170  mm.  (5  cm.),  in  an  older  one,  when  found  on  several 
examinations  and  with  due  precautions.  Above  145  mm. 
(12  cm.),  100  mm.  (5  cm.),  before  middle  age,  or  100  mm. 
(12  cm.),  180  mm.  (5  cm.),  after  it,  I  believe  is  definitely 
pathological,  if  constantly  present  as  the  average  reading. 
For  the  lower  limit  of  systolic  pressure  in  health  I  would  take 
90  mm.  (12  cm.  and  G.),  100  mm.  (5  cm.),  in  adults,  about 
80  mm.  in  children. 

I  should  like  to  lay  stress  on  the  importance  of  the  simul- 
taneous measurement  of  systolic  and  diastolic  pressure  in 
determining  normal  conditions.  The  difference  between  the 
two  is  ordinarily  25  to  40  mm.  in  my  experience,  the  lower 
figures  being  more  common  in  women.  In  old  men  50  mm. 
may  be  found,  an  expression,  in  terms  of  pressure  variation, 
of  the  well-known  large  pulse  of  the  aged.  A  pulse  which 
shows  less  than  20  mm.  difference  between  systole  and  diastole 
I  think  is  abnormally  small,  one  over  50  mm.  similarly  large. 
When  it  is  only  possible  to  estimate  one  of  the  pressures,  the 
systolic  is  the  surer  guide,  because  our  data  for  it  are  more 
complete,  and  pathological  changes  affect  it  more  than  the 
diastolic. 

LITERATURE 

V.   Basch,   S.     Die  Herzkranklieiten  bei    Arteriosclerose,   Berlin,    1901, 

p.  3. 
Bruce,  L.     Some  Observations  upon  the  General  Blood-pressure  in  Sleep- 
lessness and  Sleep.     Scottish  Med.  and  Surg.  Jour.,  1900,  vol.  vii,  p. 

109. 
Bruck,   Carl.     Ueber  den  Einfluss  kalter  hydriatischer  Prozeduren  auf 

den  Blutdruck.     Inaug.  Dissert.,  Miinchen,  1902,  April. 
Brush,  0.  E.,    and  Fayerweather,   R.     Obseiwatious  on  the  Changes  in 

Blood-pressure  during  Normal  Sleep.     Am.  Jour,  of  Physiol.,  1901, 

vol.  V,  p.  199. 
Carter,  H.  S.     Clinical  Observations  on  Blood-pressure.     Am.  Jour,  of 

the  Med.  Sci.,  1901,  vol.  cxxii,  p.  854. 
Colombo,  C.     Recherches  sur  la  pression  du  sang  chez  I'homme.    Arch. 

Ital.  de  Biol.,  1899,  vol.  xxxi,  p.  355. 
Cook,  H.  W.     The  Clinical  Value  of  Blood -pressure  Determinations  as  a 

Guide  to  Stimulation  in  Sick  Children.     Amer.  Jour,  of  the  Med. 

Sci.,  1903,  vol.  cxxv,  p.  433. 
10 


130    BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

Cook,  H.  W.,  and  Biiggs,  J.  B.  Clinical  Observations  on  Blood-pres- 
sure.    Johns  HojDkins  Hosp.  Rep.,  1903,  vol.  xi,  p.  451. 

Cushney,  A.  R.  Pharmacology  and  Therapeutics.  Phila.,  1903,  pp.  139 
and  271. 

Dolesehal.  Vergleichende  Untersuchungen  des  Gartner'schen  Tono- 
meters mit  dem  v.  Basch'schen  Sphygmomanometer.  Inaug.  Dissert., 
1900. 

Edgecomb,  W.,  and  Bain,  W.  The  Effect  of  Baths,  Massage  and  Exer- 
cise on  the  Blood-pressure.     Lancet,  1899,  vol.  i,  p.  1552. 

Ekgren,  E.  Ein  eigenartiger  Blutdruckbefund  bei  einem  Falle  von 
Mediastinaltumor.     Fortschr.  d.  Med.,  1902,  vol.  xx,  p.  105. 

Erlanger,  J.,  and  Hooker,  D.  R.  Tlie  Relation  between  Blood-pres- 
sure, Pulse-pressure  and  the  Velocity  of  Blood-flow  in  Man.  Am. 
Jour,    of  Physiol.,   1904,    vol.   x ;    Proceed,   of  Am.    Physiol.    See  , 

p.   XV. 

Federn,   S.     Ueber  Blutdruckmessung  am  Menschen.     Wien.  klin.  Wo- 

chenschr.,  1902,  vol.  xv,  p.  835. 
Gartner,    G.     Ueber  das  Tonometer.     Miinch.  med.  Wochenschr.,  1900, 

vol.  xlvii,^  p.  1195. 
Goldwater,  S.  S.     Notes  on  Blood-pressure  in  Man.     Med.  News,  1903, 

vol.  Ixxxii,  p.  926. 
Grebner,  P.,  u.,  Griinbaum,   R.     Ueber  die  Beziehungen  der  Muskelar- 

beit  zum  Blutdruck.     Wien.  med.  Presse,  1899,  vol.  xl,  p.  2033. 
Gumprecht.     Experimentelle  und  klinische  Priifung  des  Riva-Rocci'schen 

Sphygmomanometers.     Zeitschr.  f.  klin.  Med.,  1900,  vol.  xxxix,  p. 

377. 
Hayaski,    T.      Vergleichende    Blutdruckmessungen   an    Gesunden    und 

Kranken  mit  den  Apparaten  von  Gartner,  Riva-Rocci  und  Frey.     In- 
aug. Dissert.,  Erlangen,  1901,  Dec. 
Hensen,  H.     Beitrage  zur  Physiologie  und  Pathologie  des  Blutdrucks. 

Deut.  Arch.  f.  klin.  Med.,  1900,  vol.  Ixvii,  p.  438. 
Hill,  Leonard.     On  Rest,  Sleep  and  Work  and  the  Concomitant  Changes 

in  the  Circulation  of  the  Blood.     Lancet,  1898,  vol.  i,  \x  282. 
Huber,  A.    Ueber  Blutdruckbestimmungen.     Cor.  Bl.  f.  Schweiz.  Aerzte, 

1902,  vol.  xxxii,  p.  425. 
Jackson,  J.  M.     A  Few  Remarks  on  Blood-pressure.     Boston  Med.  and 

Surg.  Jour.,  1903,  vol.  cxhiii,  p.  223. 
Jarotzny,   A.     Zur  Methodik  der  klinischen   Blutdruckmessung.     Cen- 

tralbl.  f.  in.  Med.,  1901,  vol.  xxii,  p.  599. 
Jellinek,  S.     Ueber  den  Blutdruck  des  gesunden  Menschen.     Zeitschr. 

f.  klin.  Med.,  1900,  vol.  xxxix,  p.  447. 
Kapsammer,  Geo.     Blutdruckmessungen  mit  Giirtner'schen  Tonometer. 

Wien.  klin.  Wochenschr.,  1899,  vol.  xii,  p.  1279. 
Karrenstein.     Blutdrack  und  Kori^erarbeit.     Zeitschr.  f.  klin.  Med.,  1903, 

vol.  1,  p.  322. 


LITERATURE  131 

Kiesow,  F.     Experiences  avec  la  Sphygmomanomfetre  de  Mosso  sur  les 

cliangements  do  la  prcssion    du   sang,   cliez  riiomnie,   produits  par 

les  excitations  psycliiques.      Arcli.   Ital.    de    Biol.,    1895,  vol.  xxiii, 

p.  198. 
Kornfeld,  S.     Erfahrungen  iiber  Trional  als  Sclilafmittel  niit  besondei-er 

Rucksicht    auf    die    Beeinflussung    des   Blutdruckes.     "Wien.   med. 

Blatter,  1898,  vol.  xxi,  pp.  3,  25  and  40. 
—  Ueber  den  Einfluss  physischer  und  geistiger  Arbeit  auf  den  Blut- 

druck.     Wien.  med.  Bl;it.,  1899,  vol.  xxii,  pp.  G35  and  G68. 
Larrabee,  E.  0.     The  Effects  of  Exercise  on  the  Heart  and  Circulation. 

Boston  Med.  and  Surg.  Jour.,  1902,  vol.  cxlvii,  p.  318. 
Lazarus  uud  Schirmunski.     Ueber  die  Wirkuug  des  Aufenthalt  in  ver- 

danuter  Luft  auf  den  Blutdruck.     Zeitschr.  f.  klin.  Med.,  1884,  vol. 

vii,  p.  299. 
Marey,  E.  J.     La  circulation  du  sang  a  I'etat  i:)hysiologique  et  dans  les 

maladies,  Paris,  1881,  p.  334. 
Masing,  Ernst.     Ueber  das  Verhalten  des  Blutdrucks  des  jungen  und  des 

bejahrten  Menschen  bei  Muskelarbeit.     Deut.   Arch.  f.  klin.   Med., 

1902,  vol.  Ixxiv,  p.  253. 
Moritz,  O.     Der  Blutdruck  bei  Korperarbeit  gesunder  und  Herzkranker 

Individuen.     Deut.  Arch.  f.  klin.  Med.,  1903,  vol.  Ixxvii,  p.  339. 
Mosso,  A.     Sphygmomanom^tre  pour  mesurer  la  pression  du  sang  chez 

I'homme.     Arch.  Ital.  de  Biol.,  1895,  vol.  xxiii,  p.  177. 
Miiller,  Otfried.     Ueber  den  Einfluss  von  Badern  und  Douchen  auf  den 

Blutdruck  beim  Menschen.     Deut.  Arch.   f.  klin.   Med.,   1902,  vol. 

Ixxiv,  p.  316. 
Potain,  C.     La  pression  arterielle  de  I'homme  a  I'etat  normal  et  patholo- 

gique,  Paris,  1902. 
V.  Eecklinghausen.     Ueber  Biutdruckmessuug  beim  Menschen,     Arch.  f. 

exp.  Pathol,  u.  Pharmakol.,  1901,  vol.  xlvi,  j).  78. 
Eosse.     Beitrag   zur    Biutdruckmessuug   bei    Geisteskranken.     Allgem. 

Arch.  f.  Psychiatric,  1902,  vol.  lix,  p.  737. 
Schott,   Theodore.     On   Blood-pressure   under   the   Influence   of    Acute 

Overstraining  of  the    Heart.     N.   Y.    Med.   Jour.,    1902,  vol.   Ixxv, 

p.  705. 
Schiile.     Ueber  Blutdruckmessungen  mit  dem  Tonometer  von  Gartner. 

Berl.  klin.  Wochenschr.,  1900,  vol.  xxxvii,  p.  726. 
Shaw,  H.  L.  K.     Arterial  Tension   in   Childhood.     Albany  Med.  Jour., 

1900,  vol.  xxi,  p.  88. 
Sommerfeld,  L.    Blutdruckmessungen  mit  dem  Giirtner'schen  Tonometer. 

Therap.  Monatschr.,  1901,  vol.  xv,  p.  72. 
Swientochowski,  J.     Ueber  den  Einfluss  des  Alkohols  auf  die  Blutcircu- 

lation.     Zeitschr.  f.  klin.  Med.,  1902,  vol.  xlvi,  p.  284. 
Thayer,  W.  S.     On  the  Late  Effects  of  Typhoid  Fever  on  the  Heart  and 

Vessels.     Am.  Jour,  of  the  Med.  Sci.,  1904,  vol.  cxxvii,  p.  391. 


13?     BLOOD-PRESSURE   IN   THE   NORMAL   MAN 

Tsclilenoflf.  Ueber  die  Beeinflussung  des  Blutdruckes  durcli  hydria- 
tisclier  Proceduren  und  Koipeibewegungen.  Zeitschr.  f.  diat.  u. 
physikal.  Tberap.,  1898,  vol.  i,  p.  328. 

Weiss,  Hugo.  Blutdruckmessuugen  mit  Gartner's  Tonometer.  Miinch. 
med.  Wochenschr.,  1900,  vol.  xlvii,''  pp.  69  and  118. 

Wiessner.  Ueber  Blutdruckuntersnchungen  wahrend  der  Menstruation 
und  Schwangerschaft.  Oentralbl.  f.  Gynakol.,  1899,  vol.  xxiii, 
p.  1335. 

Wren,  A.  A.,  and  Oertel,  H.  A  Note  on  the  Physiological  Action  of  Alco- 
holic Stimuli.  N.  Y.  Univ.  Bull,  of  the  Med.  Sci.,  1901,  vol.  i, 
p.  184. 

Zadek,  I.  Die  Messung  des  Blutdrucks  am  Menschen.  Zeitschr,  f. 
klin.  Med.,  1881,  vol.  ii,  p.  509. 


^ 


CHAPTER  VI 

THE  BLOOD-PRESSURE  IN  DISEASE 

1.  Pathological  limits  of  blood-pressure. 

A.  Functional  and  essential  elements  of  blood-pressure. 

2.  High  blood-pressure  (Hypertension). 

A.  Functional  hypertension  and  its  causes. 

a.  Physiological ;  pharmacological ;  toxic. 

b.  Acute  cerebral  compression  and  anaemia. 

B.  Essential  or  permanent  hypertension. 

C  Causes  of  essential  hypertension. 

a.  In  arterio-sclerosis. 

b.  In  renal  disease.    Theories  of  cardiac  hypertrophy. 

c.  In  angio-sclerosis. 

D.  Effects  and  dangers  of  hypertension. 

a.  For  the  heart. 

b.  For  the  arteries. 

3.  Low  blood-pressure  (Hypotension). 

A.  Causes  of  hypotension. 

a.  Wasting  diseases. 

b.  Drugs;  infections;  haemorrhage. 

c.  Terminal  hypotension. 

B.  Collapse  and  shock. 

a.  General  features. 

b.  Experimental  evidence. 

c.  Practical  results. 

C.  Effects  and  dangers  of  hypotension. 

4.  The  relation  of  blood-pressure  to  pulse-rate  and  temperature. 

5.  Blood-pressure  as  a  guide  to  the  functional  ability  of  the  heart 

and  the  adequacy  of  the  circulation. 

Literature. 

133 


CHAPTER  VI 

THE  BLOOD-PRESSURE  IN  DISEASE 

1.   PATHOLOGICAL  LIMITS  OF  BLOOD-PRESSURE 

When  we  turn  to  the  enormous  variations  in  blood-pressure 
seen  under  pathological  conditions,  the  smaller  physiological 
fluctuations  become  far  less  conspicuous.  The  agonal  pres- 
sures of  40  mm.  (R.  R.  5  cm.)  reported  by  Hensen,  and  Cook 
and  Briggs's  case  of  cerebral  haemorrhage  with  about  400  mm. 
(R.  R.  5  cm.),  represent  the  extremes  of  tension  recorded  by 
reliable  observers  in  the  literature.  The  latter  figure  must 
contain  a  very  large  elasticity  error,  due  to  the  narrow  arm- 
piece,  but  the  absolute  value  could  scarcely  have  been  below 
300  mm.  The  more  common  readings  in  high  tension  cases 
lie  in  the  neighborhood  of  200  to  220  mm.  (12  cm.),  220  to 
260  mm.  (5  cm.). 

The  upper  limit  to  blood-pressure  is  set  by  the  reserve  force 
of  the  heart  (see  page  15)  and,  under  ordinary  circumstances, 
by  the  depressor  mechanism.  Such  enormous  pressures  as  350 
to  400  mm.  have  never  been  reported  except  as  very  temporary 
manifestations  in  cerebral  compression.  I  have  seen  a  number 
of  cases,  however,  in  which  a  pressure  between  250  and  300 
mm.  (R.  R.  5  cm.)  was  present  at  every  examination  during 
more  than  a  year.  Individual  differences  in  the  anatomical 
and  functional  state  of  the  cardiac  muscle  will  determine  the 
extent  to  which,  in  any  given  case,  increase  of  peripheral 
resistance  will  raise  the  arterial  pressure. 

Exact  data  concerning  the  minimum  arterial  pressure  at 
which  the  capillary  circulation  can  be  maintained  sufficiently 
to  support  life  are  scarce.  Experimentally,  the  complete  loss 
of  vaso-motor  tone  which  follows  destruction  of  the  spinal  cord 
is  followed  by  death  (see  page  18).  In  man  such  total  vaso- 
motor paralysis  is  probable  only  in  fatal  surgical  shock  and  in 
the  death  agony  after  acute  infectious  disease,     Hensen  places 

135 


136  THE   BLOOD-PRESSURE   IN  DISEASE 

the  lowest  systolic  blood-pressure  at  which  a  continuance  of 
the  circulation  is  possible  at  75  mm.  (R.  R.  5  cm.),  about  55  mm. 
absolute  value.  All  pressures  under  100  mm.  (R.  R.  5  cm.)  he 
considers  subnormal.  Cook  and  Briggs  give  one  chart,  from  a 
case  of  traumatic  shock  which  recovered,  with  pressure  below 
50  mm.  for  a  brief  period;  GO  mm.  they  find  usually  of  serious 
import.  Kapsammer  gives  GO  mm.  (G)  as  the  lowest  pressure 
compatible  with  life,  but  cites  one  case  in  which  a  woman  lived 
thirteen  hours  after  a  severe  fall  with  a  tonometer  reading  of 
40  mm.  John  found  35  to  40  mm.  (G)  in  advanced  phthisis  a 
few  days  before  death.  These  figures,  in  the  light  of  Gart- 
ner's own  refusal  (see  page  G8)  to  measure  below  70  mm.  with 
the  tonometer,  seem  of  doubtful  worth.  In  my  personal  ex- 
perience, pressures  below  75  mm.  (12  cm.)  have  been  very  rare, 
except  momentarily  during  surgical  operations,  where  I  have 
seen  below  40  mm.  (J.  12  cm.). 

For  diastolic  pressure  it  is  difficult  to  give  any  figures.  I 
have  never  found  it  above  200  mm.  (Erl.  5  cm.),  nor,  since  the 
use  of  the  wide  armlet,  above  180  mm. ;  but  I  have  not  ex- 
amined cases  of  cerebral  compression.  As  the  elasticity  of  the 
arterial  wall  diminishes  rapidly  with  increasing  pressure  after 
the  higher  tensions  have  been  reached  (see  page  25),  systolic 
pressure  tends  to  increase  much  more  than  diastolic  under  such 
conditions.  For  instance,  a  systolic  pressure  of  over  220  mm. 
will  commonly  be  associated  with  a  diastolic  some  GO  to  80  mm. 
lower,  instead  of  the  25  to  40  mm.  usual  at  normal  tensions. 
This  large  amplitude  of  the  pulse-wave  is  readily  seen  in  sphyg- 
mographic  tracings,  and,  when  one's  attention  has  been  drawn 
to  it,  becomes  equally  evident  to  the  finger,  if  sufficient  force  is 
exerted  upon  the  artery.  The  latter  precaution  is  necessar}", 
because  excursion  of  the  already  tense  arterial  wall  is  slight, 
unless  the  pressure  upon  its  two  sides  be  nearly  equalized. 

For  the  lower  limit  of  diastolic  pressure  I  can  give  no  fig- 
ures. My  own  observations  have  been  along  different  lines  and 
I  know  of  no  accurate  measurements  in  the  literature.  The 
Hill  and  Barnard  instrument,  as  heretofore  used,  has  given  an 
indeterminate  and  intermediate  pressure  (see  page  72). 

A.  Functional  and  Essential  Elements  of  Blood-pressure. — "We 
have  seen  (see  page  18)  that  the  vaso-motor  tone  compensates 
for  the  disproportion  between  the  total  blood- volume  and  the 


HIGH   BLOOD-PRESSURE  137 

size  of  the  vessels  it  is  called  on  to  fill.  The  lower  hmit  of 
blood-pressure  represents  the  pressure  required  to  overcome 
the  resistance  of  the  arteries  due  to  this  necessary  vaso-motor 
tone.  We  may  speak  of  this  as  the  essential  portion  of  the 
arterial  pressure,  without  which  no  circulation  is  possible.  It 
must  vary  somewhat  from  person  to  person,  but  probably  never 
amounts  to  much  less  than  50  mm.  Hg.  Such  a  minimum, 
however,  is  evidently  much  below  the  normal  pressures  of 
daily  life.  This  difference  is  due  to  the  changing  tone  of  the 
small  arteries  throughout  the  body  necessary  to  the  functional 
activity  of  the  various  organs.  We  may  speak  of  the  excess 
of  normal  pressure  over  the  essential  as  the  functional  element 
of  blood-pressure.  This  varies  from  moment  to  moment  and  is 
especially  dependent  on  the  resistance  in  the  splanchnic  circu- 
lation. Changes  in  blood-distribution  may  occur  without  any 
variation  in  the  total  peripheral  resistance,  since  dilatation  of 
one  set  of  arterioles  usually  causes  reflex  constriction  of  other 
remote  ones ;  but  such  compensation  is  seldom  perfect.  In 
muscular  exertion,  for  instance,  we  have  seen  that  pressure 
usually  rises.  The  functional  element  of  blood-pressure,  then, 
will  vary  with  changing  blood-distribution,  especially  with  the 
demands  for  blood  on  the  part  of  the  brain,  which  is  more 
dependent  on  general  blood-pressure  than  the  other  organs. 

In  states  of  continued  high  blood-pressure  due  to  a  per- 
manent increase  in  the  resistance  of  the  arteries,  the  essential 
element  of  pressure  must  rise  also.  This  is  an  important  prac- 
tical consideration,  for  a  fall  to  near  the  essential  amount  is 
dangerous  to  life  per  se.  Where  the  average  level  of  blood- 
pressure  has  been  permanently  above  200  mm.,  the  lower  limit 
must  be  above  75  mm.  Hensen  cites  a  case  of  chronic  nephritis 
with  an  agonal  pressure  of  180  mm. 

Undoubtedly  a  continued  fall  in  pressure  is  far  more  signif- 
icant of  danger  than  any  actual  numerical  value,  as  Cook  and 
Briggs  insist.     Here  the  need  of  a  graphic  record  is  manifest. 

2.   HIGH   BLOOD-PRESSURE  (Hypertension). 

By  far  the  most  valuable  results  of  clinical  sphygmoma- 
nometry  have  been  in  conditions  of  high  arterial  tension,  and 
for  a  double  reason.     First,  our  previous  methods  for  the  dis- 


138  THE   BLOOD-PRESSURE   IN   DISEASE 

coveiy  of  increased  blood-pressure  (palpation  of  pulse,  spliyg- 
raograph,  detection  of  cardiac  hypertrophy  or  accentuated 
aortic  second  sound)  were  frequently  either  inadequate  or  mis- 
leading; thus  our  diagnosis  has  gained  accuracy.  Second,  the 
existence  of  continued  high  pressure  has  far  greater  absolute 
significance  than  the  finding  of  normal  or  subnormal  tension. 

Objection  may  be  made  to  the  above  statement,  on  the  ground  that  the 
existence  of  a  hypertrophied  heart  and  ringing  aortic  second  sound  are  our 
most  valid  evidences  of  the  existence  of  hypertension.  I  will  not  dispute 
their  validity.  The  difficulty  is,  that  high  blood-pressure  is  most  common 
at  the  period  of  life  in  which  obesity  or  emphysema  freqitently  make  the 
percussion  and  auscultation  of  the  heart  well-nigh  impossible.  It  is  in 
just  such  persons  that  the  sijhygmomanometer  comes  to  our  help. 

As  to  the  sjihygmograiih,  few  physicians  will  now  claim  for  it  much 
practical  value,  though  its  educational  effect  has  been  considerable.  Assart 
from  the  fact  that  one  may  obtain  almost  any  type  of  trace  from  any  pulse, 
by  varying  the  spring-pressure,  the  forms  of  pulse-curve  generally  pic- 
tured as  indicative  of  high  tension  are  not  truly  so.  The  trace  with  a 
gradual  descending  limb  is  usually  given,  as  by  Sansom.'  This  particular 
form  of  pulse,  as  my  combined  sphygmographic  and  si^hygmomauometric 
work  taught  me,  is  regularly  obtained  when  one  narrows  an  artery  almost 
to  the  point  of  obliteration.  Thus  it  is  evidence  of  a  contracted  artery, 
which  may  go  with  low  tension,  though  frequently  found  with  high. 

The  difficulty  of  estimating  jDulse  tension  by  the  finger  has  been 
alluded  to  (see  page  M).  KrehP  admits  that  the  distinction  between  in- 
ternal tension  and  arterial  thickening  may  elude  even  the  most  experienced. 

A.  Functional  Hypertension  and  its  Causes. — a.  Physiological; 
Pharmacological;  Toxic. — Any  condition  in  which  increased 
blood-pressure  is  present,  as  a  result  of  a  temporary  cause  act- 
ing on  the  heart  or  vessels,  we  may  speak  of  as  evidencing 
functional  hypertension.  The  rise  in  pressure  due  to  excite- 
ment or  exertion  in  the  normal  man  falls  under  this  heading. 
The  marked  augmentation  of  tension  during  true  labor  pains 
is  due  to  these  physiological  causes,  plus  compression  of  the 
abdominal  vessels,  which  drives  a  large  volume  of  blood  to 
the  heart.  In  certain  nervous  affections  hypertension  occurs, 
apparently  from  reflex  vaso-constriction.  In  melancholia  it 
closely  parallels  the  intensity  of  mental  anguish,  the  stimulus 
which  calls  forth  the  reflex  originating  in  the  psychical  sphere. 

■  Saiisom,  p.  418. 

^  Krchl,  L.     Die  Erkrankungen  dcs  Ilcrzmuskels,  etc.,  p.  374. 


HIGH   BLOOD-PRESSURE  130 

In  tabes,  the  painful  visceral  crises  have  a  similar  association 
with  heightened  vaso-motor  tone,  the  stimulus  coming  from 
spinal  or  peripheral  neurons.  Acute  pain  of  other  kinds,  bili- 
ary colic  for  instance,  may  cause  considerable  hypertension. 
The  rise  in  blood-pressure  at, the  onset  of  acute  peritonitis  must 
also  be  due  to  a  reflex  vaso-constriction.  The  various  drugs 
which  stimulate  the  circulation  produce  functional  hyperten- 
sion. The  digitalis  series  act  preeminently  by  increasing  car- 
diac energy,  secondarily  through  vaso-constriction ;  adrenal 
extract  produces  its  remarkable  effects  in  the  opposite  order ; 
strychnin  and  ergot  raise  pressure  only  by  arterial  constriction. 
Camphor  and  caffein,  as  well  as  atropin,  increase  cardiac  en- 
ergy, and  peripheral  resistance  also.  This,  of  course,  applies 
only  to  therapeutic  doses.  Nicotin,  in  animals,  produces  a 
great  increase  in  blood-pressure,  and  hypertension  in  smokers 
has  already  been  mentioned.  High  pressure  is  frequent  in 
lead  poisoning  and  is  said  to  be  associated  with  acute  gout. 
The  cause  is  probably  a  toxic  one  in  both  cases.  In  many  car- 
diac patients  one  finds  the  pressure  somewhat  above  the  normal 
from  time  to  time,  quite  independently  of  the  manner  in  which 
the  heart  is  acting,  therefore  undoubtedly  due  to  complex  pe- 
ripheral influence.  In  none  of  these  conditions  does  the  systolic 
pressure  often  pass  200  mm.  (R.  R.  5  cm.),  175  mm.  (12  cm. 
or  G).  A  much  greater  hypertension,  from  increased  activity 
of  the  vaso-constrictor  centres,  is  the  asphyxial  rise  already 
considered.  This  is  met  with  clinically  in  obstructions  of  the 
upper  air-passages,  and,  in  a  less  degree,  when  more  chronic 
respiratory  or  cardiac  diseases  lead  to  deficient  oxygenation  of 
the  blood.  Toxic  hypertension  of  extreme  grade  is  seen  in 
uraemia  and  eclampsia,  because  the  large  functional  rise  is 
superimposed  on  an  existing  essential  hypertension. 

b.  Acute  Cerebral  Compression  and  Anaemia. — The  highest 
arterial  pressures  ever  recorded  in  man  have  accompanied 
acute  compression  of  the  brain,  in  fracture  of  the  base  of  the 
skull  and  apoplexy.  An  understanding  of  the  real  causes  of 
this  extreme  functional  hypertension  is  of  the  first  importance, 
if  one  would  intelligently  utilize  the  indications  of  the  blood- 
pressure  for  accurate  diagnosis  and  treatment.  The  theoretical 
basis  is  now  secure  in  its  main  features,  and  makes  one  of  the 
most  fascinating  chapters  in  experimental  pathology.    Its  full- 


140  THE   BLOOD-PRESSURE   IN   DISEASE 

est  details  may  be  found  in  the  monograph  of  Kocher,  and  it  is 
also  most  interestingly  presented  in  English  by  Hill,  and  by 
Gushing,  both  of  whom  have  made  important  contributions  to 
its  elucidation. 

Acute  cerebral  anaemia,  that,  is,  the  rapid  and  complete 
cessation  of  the  cerebral  circulation,  as  Hill  has  shown,  pro- 
duces symptoms  identical  with  complete  asphyxia.  The  usual 
sequence  is:  A.  Loss  of  consciousness.  B.  Respiratory  spasm. 
C.  Slow  heart  and  rise  of  blood-pressure  with  cessation  of  res- 
piration. D.  Fall  of  blood-pressure,  acceleration  of  heart,  and 
death.  This  indicates  distinctly  that  the  bulbar  centres  are 
first  excited  and  then  paralyzed.  If  the  animal  be  in  a  state 
of  shock,  or  the  anaemia  be  slow  in  onset,  the  excitatory  symp- 
toms fail  to  appear.  During  the  development  of  these  events, 
while  the  anaemia  is  partial,  marked  Traube-Hering  blood- 
pressure  waves  and  Cheyne-Stokes  respiration  are  common. 

Cerebral  compression  produces  the  same  bulbar  symptoms 
as  acute  anaemia.  This  seems  jjaradoxical  until  one  remem- 
bers the  mechanical  limitations  of  the  cerebral  circulation. 
Since  the  cranio-vertebral  cavity  is  closed  and  the  brain  sub- 
stance incompressible,  the  total  amount  of  blood  in  the  brain  is 
invariable,  except  for  the  slight  expansion  made  possible  by 
increased  absorption  of  cerebro-spinal  fluid  at  high  pressures. 
If,  then,  a  foreign  body  of  any  kind  be  introduced  into  the  cra- 
nial cavity,  room  can  only  be  made  for  it  at  the  expense  of  the 
blood  in  neighboring  veins  and  capillaries.  Compression  there- 
fore produces  local  anaemia,  and  the  symptoms  are  due,  not  to 
the  pressure,  but  to  the  cessation  of  blood-flow.  At  first  only 
the  veins  will  be  narrowed  and  capillary  pressure  raised.  In 
Kocher's  nomenclature,  this  is  the  stage  of  compensa- 
tion. Few  sj^mptoms  occur.  Little  increase  of  pressure  is 
required  to  bring  about  venous  stasis,  with  much  diminished 
capillary  flow,  and  brain  tension  equal  to  the  arterial.  In  this 
second  period,  Kocher's  initial  stage  of  manifest  cer- 
ebral compression,  numerous  subjective  symptoms  of 
general  cortical  or  cerebellar  anaemia  appear;  headache,  ver- 
tigo, etc.  The  ophthalmoscope  shows  the  picture  of  choked 
disc.  If  the  local  compression  be  over  an  extensive  area,  or 
situated  in  the  posterior  fossa;  or,  if  general  cerebro-spinal 
compression  be  produced,  as  in  Cushing's  experiments,  by  in- 


HIGH   BLOOD-PRESSURE  141 

troducing  fluid  into  the  cranium,  the  circulation  in  the  medulla 
will  be  affected.  The  bulbar  symptoms  at  this  period  are, 
slowing  of  the  pulsej  from  stimulation  of  the  vagus  centre, 
and  some  rise  in  pressure,  from  vaso-motor  stimulation.  The 
latter  is  not  constant. 

Any  further  increase  in  pressure  will  now  empty  the  veins 
and  capillaries,  and,  as  soon  as  it  passes  the  level  of  arterial 
pressure,  will  absolutely  cut  off  the  circulation.  This  third 
advanced  stage  of  manifest  cerebral  compres- 
sion is,  in  reality,  an  acute  cerebral  ansemia,  and  leads  to 
absolute  loss  of  function.  Now  it  is  that  the  medulla  responds 
with  an  effort  to  preserve  its  life.  The  vaso-motor  centre  auto- 
matically raises  general  blood-pressure  above  the  intracranial 
tension,  and  its  blood-flow  begins  anew.  If  the  compression 
goes  higher,  the  vaso-motor  centre  follows  with  another  rise, 
and  so,  step  by  step,  the  blood-pressure  may  keep  just  ahead 
of  advancing  brain-pressure  until  such  enormous  figures  as 
300  mm.  and  more  are  reached.  Each  rise  is  not  steadily 
maintained,  however,  but  in  many  cases  seems  to  overcompen- 
sate  and  be  succeeded  by  a  fall,  then  a  rebound,  as  ansemia  of 
the  bulb  recurs,  in  pendulum-like  oscillation.  These  are  the 
pronounced  Traube-Hering  waves,  which  may  be  appreciated  in 
making  sphygmomanometric  readings.  The  respiratory  centre 
shows  a  similar  rhythmical  variation  in  its  activity,  deep  breath- 
ing coinciding  with  the  period  of  high  blood-pressure  and  estab- 
lished circulation,  apnoea  with  its  interruption;  the  clinical 
Cheyne-Stokes  respiration.  The  vagus  centre  is  likewise  stimu- 
lated, and  the  pulse-rate  falls  materially,  as  every  one  has 
noticed  in  apoplexy.  This  in  part  antagonizes  the  good  effect 
of  vaso-motor  activity ;  at  least  the  most  complete  parallelism 
between  brain-  and  blood-pressures  is  found  after  section  of 
both  vagi.  The  complete  chain  of  events  is  beautifully  shown 
in  Cushing's  tracings. 

If  the  intracranial  tension  be  too  long  maintained,  or  go  too 
high,  the  medullary  centres  become  exhausted  and  the  final 
paralytic  stage  sets  in,  an  exact  counterpart  to  the  termi- 
nal period  of  cerebral  ansemia  or  asphyxia.  The  blood-pressure 
falls,  with  rapid,  running  pulse,  and  death  soon  ensues,  I  have 
gone  thus  at  length  into  the  experimental  findings,  because  the 
clinical  picture  is  their  perfect  duplicate.      This  will  receive 


143  THE   BLOOD-PRESSURE   IN   DISEASE 

consideration  later,  particularly  with  respect  to  surgical  treat- 
ment. Too  great  emphasis  cannot  be  laid  on  the  fact  that 
the  rise  in  blood- pressure  during  acute  cerebral 
compression  is  absolutely  essential  to  the  pres- 
ervation of  life.  On  the  other  hand,  it  cannot  be  denied 
that,  where  the  cause  of  the  increased  intracranial  tension  is  a 
haemorrhage,  the  hj-pertension  augments  it,  so  that  a  vicious 
circle  is  established.  The  same  may  occur  when  the  primary 
cause  leads  to  oedema,  with  secondary  increase  of  compression, 
the  transudation  being  hastened  by  the  greater  arterial  tension, 
so  long  as  the  venous  pressure  remains  high. 

B.  Essential  or  Permanent  Hypertension. — A  permanently 
high  level  of  blood-pressure  is  found  in  connection  with  a  last- 
ing increase  in  the  peripheral  resistance  which  the  left  ventricle 
must  overcome,  combined  with  hypertrophy  of  the  latter,  by 
which  it  is  enabled  to  meet  the  demand.  Such  changes  belong 
to  the  diseases  of  the  arteries  themselves,  which  we  include 
under  the  general  term  arterio-sclerosis,  and  to  the  cardio- 
vascular lesions  of  kidney  disease.  An  apparent  hypertension, 
that  is,  a  high  systolic,  but  not  mean  or  diastolic  pressure,  is 
seen  in  aortic  insufficiency. 

C.  Causes  of  Essential  Hypertension. — In  the  normal  animal 
or  man  the  average  level  of  blood-pressure  is  maintained  with 
great  constancy.  The  complex  nervous  mechanisms,  which 
coordinate  the  activities  of  the  cardiac  and  vascular  muscles, 
seem  to  be  directed  toward  securing  the  greatest  local  varia- 
tions in  blood-flow  with  the  least  alteration  of  general  arterial 
pressure.  We  have  seen  that  the  largest  part  of  this  regulating 
function  is  lodged  in  the  splanchnic  circulation  (see  page  22). 
If  the  blood -pressure  rises  to  the  point  where  the  heart  is  em- 
barrassed, reflex  dilatation  of  the  countless  arterioles  of  the 
abdominal  viscera,  evoked  by  the  depressor  nerve,  promptly 
causes  a  fall.  It  seems  evident,  therefore,  that  an 
abnormally  high  pressure  cannot  exist  perma- 
nently, unless  there  has  been  some  damage  to 
the  regulating  power  of  the  visceral  circula- 
tion. 

But  the  increase  in  peripheral  resistance  of  itself  would  be 
insufficient  to  account  for  a  lasting  increase  in  aortic  pressure. 
The  depressor  mechanism  is  twofold,  and  the  normal  heart 


HIGH   BLOOD-PRESSURE  143 

shields  itself  from  overstrain  by  another  reflex  through  this 
nerve,  which  automatically  slows  it  by  way  of  the  vagus.  This 
probably  only  comes  into  play  in  the  more  considerable  and 
sudden  variations  of  pressure.  It  evidences,  however,  a  limit 
to  the  reserve  force  of  the  heart.  With  increase  in  peripheral 
resistance,  increased  cardiac  energy  is  required  to  keep  the 
same  volume  of  blood  flowing  through  the  capillaries,  and,  if 
it  is  lasting,  the  working  ability  of  the  heart  must  be  raised  to 
a  higher  average  level.  This  necessitates  either  more  or  larger 
muscle  fibres.  Hence,  permanent  high  blood-pres- 
sure cannot  be  maintained  without  hypertrophy 
of  the   left   ventricle. 

a.  In  Arterio-sclerosis. — When  we  leave  the  domain  of  theory 
for  the  world  of  observed  facts,  we  find  the  most  complete 
confirmation  of  these  conclusions  in  the  case  of  arterio-sclerosis. 
In  many  cases  presenting  evident  thickening  of  the  superficial 
arteries,  high  blood-pressure  and  the  signs  of  an  enlarged  left 
ventricle,  with  ringing  aortic  second  sound,  concur.  Many 
cases  in  my  experience,  however,  have  failed  to  show  increased 
tension  with  the  sphygmomanometer,  and  the  literature  abounds 
with  similar  reports  (see  Arterio-sclerosis,  Chapter  VII,  1,  C), 
which  have  been  a  stumbling-block  to  many.  Autopsy  obser- 
vations coincide  with  this,  cardiac  hypertrophy  often  failing, 
in  spite  of  well-developed  arterio-sclerosis.  The  explanation  of 
this  lies  in  the  local  distribution  of  the  process.  The  arterial 
changes,  as  all  pathologists  know,  affect  different  portions  of 
the  vascular  system  in  a  most  irregular  way.  From  the  physi- 
ological considerations,  we  should  not  expect  an  effect  on  general 
blood-pressure,  or  on  the  heart,  where  the  splanchnic  arteries 
have  not  suffered.  This  has  been  beautifully  substantiated 
from  the  anatomical  findings  by  Hasenfeld,  and  by  Hirsch. 
In  careful  investigations  of  the  comparative  weights  of  the 
separate  portions  of  the  heart  and  the  body  weight,  by  Miil- 
ler's  method,  they  proved  definitely  that :  Arterio-sclerosis 
leads  to  a  hypertrophy  of  the  left  ventricle  only 
when  the  splanchnic  arteries  or  the  aorta  above 
the  diaphragm  are  highly  diseased.  The  arterio- 
sclerosis of  the  remaining  vascular  districts 
does  not  appear  to  exert  this  influence.  The  cor- 
respondence between  this  and  the  results  of  ligature  of  the 


144  THE  BLOOD-PRESSURE   IN   DISEASE 

same  vessels  in  the  research  laboratory  fifty  years  before,  is 
good  proof  of  the  fundamental  importance  of  physiological 
knowledge  in  clinical  medicine. 

b.  In  Renal  Disease.  Theories  of  Cardiac  Hypertrophy. — With 
the  hypertension  of  renal  disease  the  facts  admit  of  less  ready 
explanation.  Bright,  in  183G,  first  recognized  the  coincidence 
of  a  hypertrophied  heart  and  alterations  in  the  kidney,  with 
the  clinical  picture  which  bears  his  name.  He  postulated  an 
altered  composition  of  the  blood  as  the  cause,  which  he  said 
might  either  stimulate  the  heart  abnormally,  or  increase  the 
resistance  in  the  small  vessels  and  capillaries.  Though  many 
new  facts  have  been  adduced,  no  theories  have  yet  been  de- 
duced which  are  much  nearer  the  truth. 

The  older  explanations,  from  Traube  to  Cohnheim,  were 
purely  mechanical,  referring  the  hypertrophy,  either  directly  or 
indirectly,  to  increase  in  total  blood-volume,  or  to  increase  in 
resistance  due  to  the  narrowing  of  the  vascular  stream-bed  in 
the  kidneys.  Neither  of  these  are  tenable  in  the  light  of  physi- 
ological experiment,  or  of  clinical  fact.  Johnson  first  intro- 
duced the  chemical  standpoint,  supposing  that  the  accumula- 
tion of  waste  products  in  the  blood  causes  vaso-motor  spasm, 
and  secondary  hypertrophy  of  the  muscular  coat  of  the  arteries. 
O.  Israel  showed  that  the  accumulation  of  nitrogenous  waste 
(urea)  in  guinea  pigs  might  produce  hypertrophy  of  the  heart, 
and  looked  on  this  as  due  to  a  direct  stimulation.  He  con- 
sidered the  increased  work  of  the  heart  a  compensatory  mech- 
anism, counteracting  the  deficiency  of  renal  parenchyma  by 
supplying  the  remaining  portions  an  increased  amount  of  blood. 
Especially  striking  in  his  work  was  the  absence  of  any  signifi- 
cant change  in  blood-pressure,  despite  the  cardiac  hypertrophy. 
This  seems  to  me  evidence  that  in  clinical,  as  opposed  to  ex- 
perimental nephritis,  damage  to  the  splanchnic  circulation  must 
be  an  essential  factor.  Gull  and  Sutton  went  to  the  opposite 
extreme  and  looked  on  the  whole  development  of  nephritis  as 
secondary  to  a  general  change  in  the  arteries,  which  they 
euphoniously  named •"  arterio-capillary  fibrosis."  Theories  of 
nervous  and  other  origins  have  also  been  brought  forward,  but 
not  with  the  same  influence  on  medical  opinion  as  those  men- 
tioned. 

Certain  newer  facts  with  relation  to  the  cardiac  hypertrophy 


HIGH   BLOOD-PRESSURE  145 

of  Briglit's  disease  must  be  mentioned.  The  most  important  is, 
that  post-mortem  statistics  have  proven  in  most  cases  the 
hypertrophj^  of  the  whole  heart,  auricles  and  right  heart,  as 
well  as  left  ventricle.  Bamberger's  figures  showed  this,  and 
the  careful  tabulations  of  Hirsch,  by  Miiller's  method,  confirm 
it.  The  latter,  however,  in  the  early  stage  of  contracted  kid- 
ney, saw  only  the  left  ventricle  enlarged.  Even  Senator,  who 
lays  much  stress  on  the  hypertrophy  of  the  portions  of  the 
heart  which  are  not  directly  affected  by  increased  aortic  pres- 
sure, considers  it  proven  that  the  hypertrophy  of  renal  disease 
affects  the  left  heart,  either  exclusively  or  to  a  disproportionate 
degree.  He  believes  that,  in  contracted  kidney,  pure  concentric 
hypertrophy  is  found;  whereas  excentric,  or  hypertrophy  with 
dilatation,  is  the  rule  in  chronic  parenchymatous  nephritis. 
Adami,  on  the  other  hand,  disputes  the  existence  of  pure  con- 
centric hypertrophy  under  any  circumstances,  from  observation 
and  theoretical  grounds  alike.  Other  facts  of  importance  are : 
the  great  frequency  of  splanchnic  arterio-sclerosis  in  renal 
disease,  a  matter  of  common  observation  and  especially  noted 
both  by  Hasenfeld  and  Hirsch;  also  the  appearance  of  high 
blood-pressure  in  acute  nephritis  at  a  very  early  period,  cardiac 
hypertrophy  not  occurring  until  much  later,  and  requiring  at 
least  one  month  for  its  development.  Traube  first  called  at- 
tention to  this,  Riegel  later. 

Senator's  theory  distinguishes  between  the  origin  of  the 
hypertrophy  in  contracted  kidney,  and  in  other  forms  of 
nephritis.  In  the  latter,  acute  and  chronic  parenchymatous 
nephritis  especially,  he  considers  there  is  a  more  active  irritant, 
and  more  retention  of  waste  products.  The  vessels  outside  the 
kidney,  as  well  as  the  latter  itself,  are  damaged  by  the  irritant, 
and  this  causes  the  oedema,  which  for  a  time  removes  some  of 
the  irritant  and  excretives  from  the  blood.  If  the  renal  lesion 
heals,  the  irritant  has  disappeared,  oedema  is  absorbed,  and 
heart  and  vessels  again  become  normal.  If  the  process  becomes 
chronic,  the  continued  slighter  irritation  and  accumulation  of 
waste  act  as  constant  stimulants  to  heart  and  vessels,  causing 
hypertrophy  of  the  former  and  thickening  of  the  latter.  Since 
the  systemic  circulation  is  under  a  much  higher  relative  pres- 
sure, the  left  ventricle  must  be  especially  affected.  In  chronic 
interstitial  nephritis  he  presupposes  a  much  weaker  irritant, 
11 


146  THE   BLOOD-PRESSURE   IN   DISEASE 

affecting  kidneys,  heart,  and  vessels  simultaneously.  Nitrog- 
enous excretion  is  not  diminished  until  late,  when  much  renal 
epithelium  has  been  lost;  then  a  further  increase  in  pressure 
occurs.  In  consequence  of  the  heightened  pressure,  more  blood 
will  pass  through  the  kidney,  and  the  urinary  water  and  salts 
will  be  increased.  The  supposed  irritant  probably  arises  out- 
side the  kidney. 

Within  the  last  few  months  Erben  has  proposed  that  we 
should  regard  the  albumin  hunger  of  the  cells,  called  forth  by 
the  albumin  deficiency  in  the  blood,  as  the  primary  cause  of 
the  rise  in  blood-pressure  and  cardiac  hypertrophy ;  the  mech- 
anism of  its  action  being  partly  through  the  vaso-motor  system, 
partly  by  increased  work  of  the  heart  to  supply  the  demand  for 
more  nutritive  material.  Since  all  the  previous  researches  col- 
lected by  Askanazy,  as  well  as  his  own  studies  on  a  large 
material,  show  a  normal  blood  composition  and  entire  absence 
of  hydrsemia  in  the  types  of  nephritis  without  oedema — the  cases 
in  which  the  highest  blood-pressure  is  seen — this  theory  does 
not  appear  to  hold  water. 

From  the  number  of  these  theories  it  is  obvious  that  no 
single  explanation  can  harmonize  all  the  observed  facts. 
Either  new  light  must  come  which  will  unify  our  present  evi- 
dence more  completely,  or  our  generalization  must  be  less  ex- 
tended and  recognize  the  coincident  action  of  several  causes, 
now  one  and  now  another  preponderating.  From  the  standpoint 
of  the  blood-pressure,  not  of  the  cardiac  changes,  it  seems  to 
me  that  an  increase  in  peripheral  resistance,  together  with 
some  loss  of  the  regulating  function  of  the  visceral  circulation, 
must  be  assumed.  O.  Israel's  experiments,  for  instance,  in 
which  artificially  produced  nephritis  led  to  cardiac  hypertrophy, 
did  not  show  an  appreciable  rise  in  pressure.  Here  the  vessels 
were  evidently  unaffected.  The  hypertrophy,  but  not  the 
blood-pressure,  went  hand  in  hand  with  the  loss  of  secreting 
renal  substance.  In  human  nephritis  such  a  definite  relation 
does  not  exist.  Besides,  with  all  due  allowance  for  the  un- 
doubted hypertrophy  of  the  whole  heart  in  contracted  kidney, 
it  seems  to  me  that  overmuch  stress  is  laid  on  it,  from  the 
small  number  of  weighings  by  Miiller's  method,  compared  with 
the  impression  of  pathologists  from  many  thousand  autopsies. 
Even  Hirsch  admits  that  the  early  cases  do  not  show  it,  and 


HIGH   BLOOD-PRESSURE  147 

that  left  ventricular  hypertrophy  predominates  in  all  cases. 
Observations  for  a  number  of  years  will  be  necessary  to  clear 
up  this  point,  and  systematic  blood-pressure  records  on  all 
nephritic  patients  will  add  greatly  to  the  value  of  the  post- 
mortem findings,  which  allow  us  to  judge  of  physiological 
alterations  only  by  inference. 

Whether  the  increased  resistance  and  the  loss  of  splanchnic 
regulation  are  one  and  the  same,  that  is  due  to  narrowing  of 
the  visceral  circulatory  area,  either  through  vaso-motor  spasm 
or  anatomical  change;  or  whether  some  of  the  increased  re- 
sistance lies  outside  the  abdominal  vessels,  is  another  problem. 
Again  careful  pressure  observations  during  life  will  help  us. 
Krehl  ^  thinks  continued  spasm  a  priori  unlikely.  Hirsch  and 
Beck  were  unable  to  prove  increased  viscosity  of  the  blood  in 
the  majority  of  cases  of  nephritis  they  examined,  but  it  was 
markedly  greater  than  normal  in  three  cases  of  genuine  con- 
tracted kidney.  More  studies  of  this,  and  of  the  osmotic  pres- 
sure of  the  blood,  are  to  be  desired,  since  general  peripheral 
resistance  might  thus  be  raised.  It  is  also  conceivable  that 
increased  blood- volume,  which  in  the  presence  of  a  normal 
vaso-motor  mechanism  is  powerless  to  raise  pressure,  may 
contribute  to  this  end  when  the  regulation  is  disturbed.  As  a 
factor  in  chronic  interstitial  nephritis  it  cannot  be  considered, 
but  in  the  acute  forms,  where  actual  retention  occurs,  it  may 
be  significant,  like  Erben's  albumin  hunger  of  the  cells.  Cer- 
tainly contemporary  opinion  inclines  toward  the  primary 
stimulation  of  the  heart  as  the  cause  of  its  hypertrophy.  I 
am  quite  willing  to  admit  this  as  one  factor,  especially  in  the 
various  forms  of  parenchymatous  nephritis.  I  also  think  that 
the  hypertrophy  of  the  whole  heart  in  chronic  Bright's,  which 
appears  late,  probably  owes  its  origin  to  this  cause ;  the  reten- 
tion of  waste  products,  which  occurs  during  the  latter  part  of 
chronic  cases  being  the  possible  stimulant.  Nevertheless,  for 
the  reasons  already  given,  I  cannot  abandon  the  opinion  that 
increased  resistance  and  diminished  splanchnic  compensation 
are  essential  hypotheses  for  the  comprehension  of  the  arterial 
hypertension,  in  the  light  of  our  present  knowledge,  whatever 
be  the  source  of  the  irritant  which  evokes  them. 

>  Krehl.     Pathol.  Phys.,  p.  37. 


148  THE   BLOOD-PRESSURE   IN  DISEASE 

c.  In  Angio-sclerosis. — One  other  class  of  cases  with  essen- 
tial hypertension  remains  to  be  considered.  It  is  entirely  a 
clinical  group,  and  one  which  depends  for  its  differentiation 
largely  on  the  sphygmomanometer.  In  it  are  comprised  all 
those  persons  who  show  permanently  high  blood-pressure,  but 
neither  discoverable  arterial  thickening,  nor  any  clinical  evi- 
dence of  nephritis  after  repeated  examination,  not  only  as  to 
the  presence  of  albumin  and  casts,  but  with  reference  to  the 
quantity  of  water  and  solids  excreted  as  well.  v.  Basch  has 
done  the  greatest  service  through  insisting  on  the  recognition 
of  this  condition,  which  he  calls  angio-sclerosis.  While  I  con- 
sider many  of  his  cases  of  so-called  ' '  manifest  angio-sclerosis  " 
as  undoubted  chronic  nephritis,  and  am  not  convinced  as  to 
many  of  his  pseudo-type,  there  remains  the  large  group,  which 
he  names  "latent  angio-sclerosis."  Huchard  has  a  similar 
picture  in  mind  in  his  "presclerosis."  This  condition,  high 
blood-pressure,  some  cardiac  hypertrophy,  and  symptoms  ref- 
erable as  a  rule  to  relative  insufficiency  of  the  heart,  in  middle- 
aged  or  elderly  persons,  who  give  no  evidence  of  peripheral 
arterio-sclerosis  or  chronic  Bright's,  is  comparatively  frequent 
in  my  experience.  I  am  convinced  that  its  recognition  and 
treatment  are  important.  The  special  consideration  of  it  will 
follow  later.  As  to  its  cause,  early  sclerotic  changes  in  the 
splanchnic  vessels,  as  maintained  by  v.  Basch,  seems  the  most 
probable. 

D.  Effects  and  Dangers  of  Hypertension. — Hypertension  is  not 
merely  a  symptom  of  diagnostic  and  prognostic  value,  nor  is  it 
to  be  considered  only  as  an  effect  of  causes  acting  on  the  heart 
and  vessels.  It  is  of  itself  a  source  of  altered  function 
throughout  the  circulatory  system,  which  leads  to  further  sec- 
ondary changes.  Those  cannot  in  all  cases  be  clearly  sepa- 
rated from  the  primary  changes  producing  the  high  pressure, 
but  they  may  frequently  be  distinguished  anatomically  as  well 
as  theoretically. 

a.  For  the  Heart.— F or  the  heart,  increased  pres- 
sure necessitates  increased  work  to  maintain 
the  same  intensity  of  capillary  circulation.  Of 
greater  importance  than  the  need  for  absolute  increase  of  car- 
diac energy,  is  the  relatively  greater  increase  in  the  demands 
during  muscular  exertion.     The  mechanical  disadvantage  of 


HIGH   BLOOD-PRESSURE  149 

increased  peripheral  resistance  is  the  same  in  kind  as  that  of 
narrowing  the  aortic  orifice.  Benno  Lewy  ^  has  demonstrated 
for  this,  as  for  the  other  obstructive  lesions,  the  extreme  grade 
to  which  the  necessity  for  a  larger  blood-flow  during  exertion 
augments  the  work  of  the  heart.  Since  this  additional  output 
may  raise  the  heart's  work  as  much  as  thirteen-fold,  it  is  evi- 
dent that  hypertension,  like  valvular  lesions,  will  sooner  lead 
to  failure  of  compensation  in  those  whose  occupations  are 
laborious. 

The  influence  of  nutrition  is  equally  potent.  It  is  well 
known  that  hypertrophy  cannot  occur  unless  the  heart-muscle 
is  well-nourished  (Krehl,  Benno  Lewy,  Rosenbach,  etc.). 
Therefore  accommodation  to  hypertension  is  apt  to  be  more 
complete  in  the  young  and  vigorous  and  fail  most  conspicu- 
ously when  wasting  disease  is  present  (see  Sibson's  cases). 
Most  important,  however,  as  a  source  of  danger,  is  the  occur- 
rence of  structural  alterations  in  the  wall  of  the  heart.  Hasen- 
feld  and  Romberg  showed  in  healthy  dogs,  that  hypertrophied 
heart-muscle  may  possess  the  same  reserve  force  as  the  nor- 
mal. Nevertheless,  as  Krehl ^  says :  "It  can,  but  unfortu- 
nately it  usually  does  not.  In  reality  the  old  dictum  of  medi- 
cine remains  justified :  A  hypertrophic  heart  is  not 
so  good  as  a  normal  one."  Whether  we  consider  the 
damage  to  the  hypertrophic  muscle  as  due  to  degenerative 
changes,  as  did  the  older  pathologists;  as  secondary  to  scle- 
rosis of  the  coronary  arteries  (Krehl, ^  v.  Basch,  Huchard's 
cardio-sclerosis) ;  or  adopt  the  most  recent  view  of  Albrecht, 
that  chronic  interstitial  and  parenchymatous  inflammatory 
processes  are  an  integral  part  of  the  hypertrophic  process;  at 
least  we  may  feel  sure  that,  sooner  or  later,  the  accommodative 
power  of  such  a  heart  will  become  insufiicient  for  the  demands 
upon  it. 

The  degree  of  hypertension  and  the  time  of  development  of 
the  cardiac  insufficiency  have  no  relation  to  one  another. 
V.  Basch,  in  his  book,  has  brought  this  out  admirably,  and  his 
findings  coincide  with  my  experience.  An  increasingly  high 
blood-pressure  is  a  much  more  serious  sign  than  any  absolute 

'  Lewy,  Benno.     Zeitschr.  f.  klin.  Med.,  1897,  vol.  xxxi,  p.  532. 

2  Krehl,  L.     Pathol.  Physiol.,  p.  51. 

2  Krehl,  L.    Erkrank.  des  Herzmuskels,  p.  350. 


150  THE  BLOOD-PRESSURE   IN   DISEASE 

value,  especially  when  treatment  fails  to  influence  it.  With 
the  development  of  symptoms  from  the  side  of  the  heart  the 
pressure  may  fall,  or  it  may  even  rise ;  in  the  latter  case  indi- 
cating a  still  increasing  peripheral  resistance ;  in  the  former, 
of  course,  a  diminution  in  cardiac  energy. 

The  most  common  complaints  one  meets  with  in  this  con- 
dition are :  dyspnoea  on  exertion,  or  the  more  severe  spontane- 
ous attacks,  which  we  call  cardiac  asthma ;  precordial  distress, 
varying  in  degree  from  slight  substernal  oppression  or  a  feeling 
of  tightness,  to  the  most  intense  angina  pectoris;  and  subjec- 
tive or  objective  disturbances  of  the  heart's  rate  or  rhythm. 
Attacks  of  oedema  of  the  lungs  are  rarer  and  depend  on  the 
sudden  development  of  weakness  of  the  left  ventricle,  throw- 
ing more  work  on  the  right  than  it  can  perform.^  If  the  right 
ventricle  gradually  becomes  secondarily  insufficient,  then  gen- 
eral venous  congestion  and  oedema  set  in.  Death  may  come 
suddenly  in  an  anginal  seizure,  or  an  attack  of  cardiac  asthma 
or  pulmonary  oedema ;  or  it  may  be  the  result  of  gradual  asys- 
tole. 

b.  For  the  Arteries. — Not  the  heart  alone  suffers  from  the 
effect  of  continued  high  blood-pressure,  but  the  arteries  as 
well.  The  elastic  distensibility  of  the  arterial 
wall  decreases  with  increasing  tension.  The 
proofs  of  this  have  been  cited  (see  page  25).  The  immediate 
effect  on  the  character  of  the  pulse,  a  greater  systolic  elevation 
of  pressure,  has  been  explained.  Thus,  in  all  high  tension 
pulses,  where  the  circulation  is  at  all  adequate,  one  finds  a 
difference  of  50  to  80  mm.  between  systolic  and  diastolic  pres- 
sures. The  continued  overstretching  of  the  walls  of  the  arte- 
ries leads  in  many  cases  to  a  general  dilatation  of  the  larger 
vessels,  which  are  subject  to  the  greatest  systolic  strain.  The 
most  straightforward  examples  of  this  are  seen  in  aortic  in- 
sufficiency, where  the  systolic  elevation  of  pressure  is  sudden 
and  extreme,  but  the  general  mean  is  not  markedly  altered. 
Every  clinician  must  have  seen  examples  of  such  dilatation  of 
the  abdominal  aorta,  carotid,  subclavian,  brachial,  radial,  and 
femoral  arteries,  as  a  result  of  aortic  regurgitation  consecutive 
to  rheumatic  endocarditis  in  young  people,  where  primary  arte- 

'  See  Cohnheini  and  Welch.  Ueber  acutes  Lungenoedem.  Cohnheim's 
Gesam.     Abhandlungen.    Berlin,  1885,  p.  593. 


HIGH  BLOOD-PRESSURE  151 

rial  disease  is  practically  excluded,  Hasenfeld  and  Romberg 
noted  a  similar  dilatation  in  animals  with  experimental  aortic 
leakage.  I  have  had  evidence,  both  by  physical  signs  and 
fluoroscope,  of  a  dilated  ascending  aorta,  which  simulated 
aneurism,  in  two  such  cases.  In  chronic  nephritis,  a  dilated 
aorta  is  not  infrequent  at  autopsy,  but  here  arterial  disease  as 
a  primary  factor  is  harder  to  eliminate.  Certainly  the  me- 
chanical moment  is  an  efficient  aid  in  its  production,  as  of  the 
more  general  dilatations,  which  are  also  found  in  patients  with 
Bright's  or  some  forms  of  arterio-sclerosis. 

The  smaller  arteries  may  undergo  dilatation  as  a  result  of 
the  increased  internal  tension  to  which  they  are  subjected,  a 
late  event  of  degenerative  changes  in  their  coats,  due  to  gen- 
eral arterial  disease.^  Rosenbach  believes  that  with  increased 
blood-pressure  the  arterial  walls  hypertrophy,  because  of  the 
extra  work  they  are  called  on  to  perform  and  the  greater 
blood-supply  which  he  considers  they  receive;  the  later  degen- 
erative changes  he  calls  decompensative,  thus  classifying 
practically  all  the  arterio-sclerotic  changes  in  the  arteries,  as 
opposed  to  the  arterioles,  as  secondary  to  hypertension.  The 
hypertrophy  of  the  muscularis,  described  by  Johnson,  lends 
itself  to  a  similar  explanation;  but  so  good  an  observer  as 
Senator  ^  thinks  it  a  chance  find.  He  insists  that  intima  and 
adventitia  alone  show  constant  increase  in  thickness  in  chronic 
nephritis.  Recent  experiments  by  Sumikawa  are  of  special  in- 
terest. He  tied  off  a  considerable  portion  of  artery  and  sub- 
jected it  to  high  internal  pressure,  by  the  injection  of  salt  solu- 
tion. The  rupture  of  some  of  the  elastic  fibres,  thus  produced, 
was  followed  by  proliferation  of  the  media,  and  of  the  intima 
to  an  even  greater  degree.  We  may  therefore  say  that  the 
differentiation  of  the  complex  arterial  lesions,  and  of  the  order 
of  their  development  is  impossible  to-day;  but  that  many  of 
them  are  of  a  secondary  nature  and,  in  certain  of  their  fea- 
tures, due  to  increased  internal  tension,  seems  assured. 

The  diminished  distensibility  of  the  arteries, 
and  the  sharp  rise  in  pressure  at  every  systole 
of    the    ventricles,    introduces    another    danger, 

^  See  Krehl.  Pathol.  Physiol.,  p.  108,  and  Erkrank.  des  Herzmuskels, 
p.  339. 

3  Senator.    Erkrankungen  der  Nieren,  p.  118, 


152  THE   BLOOD-PRESSURE   IN  DISEASE 

that  of  rupture.  We  know  that  the  healthy  artery  can 
stand  a  strain  which  the  most  extreme  hypertension  never  ap- 
proximates. Given  the  degenerative  changes,  however,  which 
are  common  in  diseases  associated  with  high  blood-pressure, 
plus  the  sudden  augmentation  of  tension  which  excitement  and 
exertion  cause,  and  rupture  becomes  probable.  Experience 
bears  this  out.  Of  Bright's  original  cases  a  large  proportion 
died  of  apoplexy,  and  the  occurrence  of  cerebral  haem- 
orrhage as  a  common  termination  of  Bright's 
disease  has  been  well  established.  All  the  recent 
literature  of  clinical  sphygmomanometry  confirms  it,  from  the 
standpoint  of  high  arterial  pressure.  Of  course  the  real  cause 
lies  in  the  local  weakening  of  a  cerebral  vessel.  One  must  not 
consider  that  height  of  blood-pressure  is  any  index  of  the  prob- 
ability of  an  apoplectic  seizure,  save  in  a  general  way. 

The  other  dangerous  condition  due  to  giving  way  of  the 
arterial  wall,  namely,  aneurism,  also  depends  primarily  on 
the  local  lesion,  secondarily  on  the  general  pressure.  One  sees 
a  number  of  cases  where  high  tension  is  not  in  evidence.  When 
present,  however,  it  is  one  more  element  in  the  already  unfa- 
vorable prognosis.  Nose-bleed  is  a  minor  manifestation  of  the 
same  tendency. 

3.    LOW    BLOOD-PRESSURE   (Hypotension) 

For  practical  purposes  we  may  draw  the  line  between  low 
normal  and  subnormal  systolic  pressure  at  100  mm.  (R.  R. 
5  cm.),  90  mm.  (12  cm.  and  G).  Of  course  the  real  dividing 
line  is  an  individual  one,  to  determine  which  we  should  have 
previous  records  of  the  same  patient  in  health.  This  is  seldom 
possible,  and  we  must  take  the  lowest  normal  as  our  standard, 
just  as  we  do  for  the  leucocyte  count.  Sex,  age,  occupation, 
and  muscular  development  may  also  be  taken  into  account  in 
our  judgment,  if  not  put  into  definite  figures.  One  may  at  any 
rate  bo  sure  that  70  mm.  is  very  marked  hypotension. 

A.  Causes  of  Hypotension. — a.  Wasting  Diseases. — In  medical 
practice,  hypotension  is  commonly  seen  in  wasting  diseases 
and  cachectic  states,  such  as  advanced  phthisis,  carcinoma  of 
the  stomach,  and  general  paralysis  of  the  insane.  If  anything 
could  be  called  essential  hypotension,  this  form  would  most 


LOW   BLOOD-PRESSURE  153 

justly  deserve  the  name,  for  it  seems  to  me  unquestionably 
associated  with  a  reduction  in  all  three  factors  concerned  in 
maintaining  the  blood-pressure.  All  the  life  processes  are 
carried  on  at  the  lowest  possible  level,  that  is,  the  functional 
element  of  peripheral  resistance  is  reduced  to  its  lowest  terms. 
The  brown  atrophy  of  the  heart,  found  post  mortem  in  these 
very  conditions,  bespeaks  a  diminished  output  of  cardiac  en- 
ergy ;  and  the  reduction  of  total  blood- volume  is  equally  shown 
by  the  small  and  empty  pulse  during  life,  and  the  bloodlessness 
of  the  tissues  after  death. 

b.  Drugs ;  Infections ;  Haemorrhage. — Temj)orary  falls  in  pres- 
sure result  from  certain  drugs  which  cause  vaso-dilatation,  the 
nitrites  especially.  Poisonous  doses  of  drugs,  which  paralj^ze 
the  vaso-motor  centre  or  heart,  naturally  result  in  a  fatal  fall. 
Chloroform  is  the  most  important  of  these,  and  low  arterial 
pressure  occurs  early  in  chloroform  anaesthesia  and  needs  care- 
ful watching.  Various  infections  and  toxaemias  may  be  accom- 
panied by  hypotension  in  some  persons,  and  are  most  apt  to  be 
when  severe.  Typhoid  fever  is  more  frequently  hypotensive 
in  the  average  case  than  the  other  acute  diseases,  pneumonia 
least.  Haemorrhage,  when  profuse,  or  occurring  in  persons 
whose  vaso-motor  centres  have  lost  their  normal  function,  as. 
in  shock  or  severe  infections,  leads  to  a  rapid  reduction  of 
pressure. 

0.  Terminal  Hypotension. — It  goes  without  saying  that  the 
process  of  dissolution  is  attended  by  a  fall  in  blood-pressure  to 
the  zero  mark,  irrespective  of  which  particular  leg  of  the  tripod 
of  life  gives  out  first.  The  rapidity  with  which  this  terminal 
or  agonal  hypotension  develops,  differs  much.  In  sudden  car- 
diac death,  as  seen  in  aortic  disease  or  angina  pectoris,  or  in 
enormous  haemorrhage,  it  comes  almost  instantaneously.  After 
lingering  illness,  pressures  below  60  mm.  (R.  R.  5  cm.)  may 
persist  for  several  days  before  the  termination.  In  such  cases 
the  hypotension  is  of  some  value  as  a  sign  of  the  impending 
end,  but  usually  it  is  but  one  of  many.  As  a  rule,  the  terminal 
fall  in  pressure  may  be  measured  by  minutes  or  hours,  not 
by  days. 

B.  Collapse  and  Shock. — a.  General  Features. — There  are  two 
conditions,  the  one  medical,  the  other  surgical,  in  which  hypo- 
tension is  more  than  a  symptom ;  it  is  the  essential  manif esta- 


154  THE   BLOOD-PRESSURE   IN   DISEASE 

tion  of  the  serious  disorder  of  function  which  lies  back  of  the 
chnical  picture,  and  it  is  the  chief  source  of  danger  to  hfe. 
These  two  conditions  are  called  collapse  and  shock.  Collapse 
is  seen  in  acute  disease  at  the  height  of  the  infection,  and,  when 
severe,  results  rapidly  in  a  fatal  issue.  It  follows  large  hsem- 
orrhages,  but  in  this  form  will  not  be  discussed  here,  since  the 
causative  factor,  loss  of  blood-volume,  is  somewhat  different. 
It  also  makes  an  appearance  under  the  same  circumstances 
which  lead  to  shock,  especially  prolonged  operations,  in  par- 
ticular those  involving  repeated  manipulation  of  the  intestines 
and  insults  to  sensory  nerve  trunks,  or  accompanied  by  profuse 
haemorrhage.  Though  there  is  much  discussion  alike  over  the 
definition  and  the  causation  of  shock,  there  seems  no  good 
reason  for  considering  it  more  than  the  fully-developed  condi- 
tion, of  which  collapse  is  the  forerunner.  Both  shock  and  the 
collapse  of  the  acute  infections  have,  in  the  last  few  years,  been 
the  subject  of  much  fascinating  experimental  study.  The 
former  has  aroused  widespread  interest  among  surgeons,  and 
will  be  considered  in  detail  in  the  chapter  devoted  to  blood- 
pressure  in  surgical  conditions.  The  latter,  unfortunately,  in 
view  of  the  importance  of  the  work  done,  has  attracted  much 
less  attention  than  it  should  from  physicians  and  pathologists 
in  our  country. 

Sudden  death  during  the  height  of  an  acute  infection,  be  it 
pneumonia  or  diphtheria,  or,  as  is  less  usual,  typhoid  fever, 
nine  times  out  of  ten  is  set  down  on  the  death  certificate,  and  in 
more  pretentious  medical  literature,  as  ' '  heart  failure. "  How- 
ever, the  phenomena  often  resemble  those  of  profuse  hsemor- 
rhage,  and,  in  typhoid  fever  especially,  the  differential  diag- 
nosis between  the  two  offers  great  practical  difficulty.  The 
pulse  in  collapse  becomes  small,  empty,  and  rapid;  there  is  no 
sj^stemic  venous  congestion  or  pulmonary  oedema;  merely 
extreme  prostration,  cold  skin,  the  changed  facies,  and  the 
ineffectual  heart.  This  striking  similarity  to  death  from  haem- 
orrhage, and  the  absence  of  the  usual  sequences  of  cardiac 
asystole,  have  made  numerous  clinicians  interrogate  the  ordi- 
nary interpretation  and  ask  themselves  whether,  after  all,  the 
patient's  vaso-motor  mechanism  might  not  have  failed;  thus, 
as  it  were,  bleeding  him  to  death  into  his  own  veins  (see 
page  18). 


LOW  BLOOD-PRESSURE  155 

b.  Experimental  Evidence. — This  question  has  been  ap- 
proached from  the  experimental  side  during  the  last  five  years, 
with  results  which  seem  to  me  quite  conclusive.  The  first 
paper  of  Romberg  and  Passler  should  be  read  by  every  one 
who  cares  to  see  purely  clinical  problems  elucidated  by  the 
methods  of  experimental  physiology.  They  studied  the  fatal 
collapse  which  occurred  in  rabbits  after  infection  with  the 
pneumococcus,  the  bacillus  pyocyaneus,  and  the  diphtheria 
bacillus;  the  first  producing  a  true  septicaemia,  the  latter  a 
local  lesion  with  general  toxaemia.  All  of  the  two  hundred 
and  fifty  animals  used  were  autopsied,  and  the  heart  and  other 
important  organs  examined  microscopically.  Their  method 
consisted  in  observing  the  mean  carotid  pressure  at  different 
stages  of  the  disease,  and  the  effect  upon  it  of  (1)  abdominal 
massage,  which  increased  the  work  of  the  heart,  by  supplying 
it  with  more  blood ;  (2)  compression  of  the  aorta  above  the  dia- 
phragm, which  makes  the  work  of  the  heart  maximal;  (3) 
irritation  of  the  nasal  mucous  membrane  with  a  Faradic  cur- 
rent, which  causes  extreme  reflex  vaso-constriction ;  and  (4) 
short  asphyxia  (30  sees.),  which  acts  similarly,  only  on  both 
medullary  and  spinal  vaso-motor  centres,  while  sensory  stimu- 
lation affects  only  the  centre  in  the  medulla.  They  reasoned 
that,  should  there  be  no  rise  in  pressure  from  sensory  irritation 
or  suffocation,  while  abdominal  massage  and  hgature  of  the 
aorta  still  called  forth  a  well-marked  one,  then  the  heart  must 
be  functionally  capable  and  the  vaso-motor  mechanism  para- 
lyzed. To  determine  whether  the  central  or  peripheral  vaso- 
motor mechanism  was  at  fault,  they  used  injections  of  barium 
chloride,  which  cause  constriction  of  the  arteries  by  purely 
local  action  upon  them. 

Their  experiments  showed  that  the  blood-pressure  and  the 
response  to  all  the  procedures  remained  perfectly  normal 
throughout  the  early  stage  of  the  disease,  being  unaffected  by 
the  fever.  The  greatest  elevation  of  pressure  was  obtained  on 
stimulatuig  the  mucous  membrane  of  the  nose.  When  the 
animals  showed  signs  of  impending  collapse  in  their  behavior, 
the  blood-pressure,  though  still  normal,  began  to  sink,  while 
the  heart  beat  more  forcibly.  Hand  in  hand  with  this  went  a 
great  reduction  in  the  rise  of  pressure  from  sensory  irritation, 
a  moderate  decrease  in  the  asphyxial  elevation,  but  as  high  a 


156  THE   BLOOD-PRESSURE   IN  DISEASE 

pressure  as  before  after  abdominal  massage.  In  many  cases 
the  pressure  did  not  fall  until  the  reflex  rise  had  been  almost 
abolished,  evidently  being  maintained  by  increased  cardiac 
energy,  in  spite  of  the  vascular  dilatation.  Finally,  in  complete 
collapse,  which  developed  very  rapidly,  the  aortic  pressure  fell 
to  the  lowest  level,  as  after  destruction  of  the  spinal  cord ;  no 
reflex  rise  could  be  obtained,  but  abdominal  massage  gave  an 
immediate  elevation.  It  was  evident,  therefore,  that  the 
circulatory  disturbance  at  the  height  of  the 
infection  depended  absolutely  upon  a  paralysis 
of  the  vessels,  not  upon  any  damage  to  the 
force   of  the   heart. 

As  regards  their  reaction  to  compression  of  the  thoracic 
aorta,  the  diphtheria  animals  showed  a  divergence  from  the 
pneumococcus  ones ;  the  latter  evincing  practically  normal  car- 
diac reserve  force,  while  the  former  showed  a  distinct  falling 
off.  Anatomically,  also,  the  diphtheria  hearts  had  suffered 
damage,  parenchymatous  degeneration  being  well  marked,  as 
in  clinical  diphtheria.  The  pneumococcus  animals  had  scarcely 
any  change  in  their  cardiac  muscle.  This  evidence  of  weakness 
in  the  heart  muscle  in  diphtheria  was  of  minor  importance,  the 
real  cause  of  death  in  all  cases  being  the  complete  loss  of  vaso- 
motor tone.  By  intravenous  injections  of  barium  chloride  they 
proved  decisively  that  this  was  due  to  central  paralysis. 
Their  conclusions  were,  that  all  three  organisms  used  damage 
the  circulation  through  paralyzing  the  vaso-motor  centres 
throughout  the  medulla  and  cord;  this  vaso-motor  paralysis 
leads  to  a  fall  in  blood-pressure,  and  further,  to  a  changed 
blood  distribution;  the  splanchnic  circulation  is  overfilled,  the 
brain,  muscle,  and  skin  vessels  are  empty;  the  heart  is  not 
affected,  except  secondarily  through  insufficient  blood-supply. 
These  conclusions  applied  only  to  the  deaths  at  the  height  of 
the  infection,  not  to  those  at  a  later  stage  in  the  disease,  or 
during  convalescence.  Another  piece  of  work  from  the  Leipzig 
clinic,  by  Hollwachs,  published  at  the  same  time,  brought  these 
later  deaths,  in  diphtheria,  into  relation  with  the  graver  struc- 
tural changes  in  the  heart  (acute  infectious  myocarditis). 

In  line  with  this  investigation,  Heineke  showed  later  that 
a  paralysis  of  the  medullary  centres  is  the  cause  of  death  in 
perforative  peritonitis,  a  condition  almost  invariably  associated 


LOW   BLOOD-PRESSURE  157 

with  profound  collapse  in  man.  He  drew  attention  to  the 
fact  that  the  heart  continued  to  beat  after  respiration  had 
ceased,  Hasenfeld  and  Feny  vessy  also  demonstrated  the  slight 
functional  damage  to  the  heart  in  acute  fatty  degeneration 
caused  by  phosphorus,  and  considered  the  cause  of  death  in 
artificial  phosphorus  poisoning  a  vascular  paresis;  a  position 
which  Pal  justifies  from  clinical  observations. 

Hasenfeld  and  Feny  vessy,  as  well  as  Romberg  and  Passler, 
found  some  loss  of  power  in  the  fatty  hearts,  nevertheless. 
Since  that  time,  the  cardiac  factor  in  collapse  during  diphtheria 
has  received  special  attention.  Roily,  by  carefully  planned 
experiments  with  diphtheria  toxin,  injected  into  an  isolated 
heart-lung  circulation  (Hering's  method),  found  a  direct  action 
of  the  poison  upon  the  heart,  which  led  rapidly  to  a  fatal  issue 
in  spite  of  artificial  respiration.  Most  interesting  in  his  exper- 
iments was  the  length  of  the  latent  period,  often  as  much  as 
twenty-four  hours,  during  which  no  symptoms  occurred  after 
the  most  enormous  doses  of  toxin.  When  the  heart  began  to 
fail,  death  followed  rapidly,  and  nothing  could  ward  it  off  ; 
perfusion  of  the  heart  with  normal  blood  being  insufficient  to 
wash  out  the  poison.  Roily  predicated  a  gradual  fixation  of 
the  toxin  in  the  cardiac  muscle  as  the  explanation  of  these 
phenomena.  Of  late  v.  Stejskal  has  combatted  the  theory  of 
vaso-motor  death  in  diphtheria,  and,  in  elaborate  experiments, 
in  which  he  measures  aortic  and  left  auricle  pressures  simul- 
taneously, endeavors  to  show  that  failure  of  the  heart  is,  after 
all,  the  primary  cause  of  the  fatal  hypotension.  His  method  is 
not  wholly  convincing,  and  he  admits  the  involvement  of  respi- 
ratory and  vaso-motor  centres  as  well.  Passler  and  Roily 
have  met  his  criticisms  and,  by  a  more  thorough  application  of 
his  own  method,  they  have  shown  that,  while  damage  to 
the  heart  is  actual,  nevertheless  it  is  not  the 
cause  of  death  at  the  acme  of  the  infection. 
This,  in  diphtheria,  as  in  pneumococcus  septi- 
caemia, is  due  to  vaso-motor  paralysis,  which 
the    heart    is    able    for    a    time    to    counteract. 

For  surgical  shock,  Crile's  exhaustive  experiments  seem  to 
give  us  an  equally  secure  basis  for  regarding  the  cHnical  pic- 
ture as  one  of  extreme  and  dangerous  hypotension,  due  to  ex- 
haustion of  the  central  vaso-motor  mechanism.    He  approached 


158  THE   BLOOD-PRESSURE   IN   DISEASE 

the  problem  by  similar  methods,  and  his  book,  ' '  Blood-Pressure 
in  Surgery,"  should  be  read  by  all  who  desire  the  evidence  at 
first  hand.  His  experiments  numbered  two  hundred  and  fifty - 
one,  on  two  hundred  and  forty-three  animals.  All  were  re- 
duced to  full  surgical  anaesthesia.  Shock  was  induced,  as  a 
rule,  by  exposure  and  manipulation  of  the  intestines,  or  by 
skinning  the  animal.  The  blood-pressure  fell  progressively, 
and  the  reflex  rise  from  stimulation  of  the  sciatic  nerve,  or 
peripheral  irritation  (burning  the  paw),  diminished  pari  passu 
with  it.  When  the  animal  was  in  profound  shock,  which  re- 
quired at  least  half  an  hour  for  its  development,  the  blood- 
pressure  was  about  20  mm.,  practically  no  reflex  rise  could  be 
obtained,  and  strychnin  was  powerless  to  affect  it.  The 
sequence  of  events  was  identical  in  animals  whose  hearts  had 
previously  been  isolated  from  the  central  nervous  system. 

In  the  most  profound  shock  it  was  possible  to  raise  the 
blood-pressure  to  almost  any  level,  and  maintain  it  there  for 
long  periods  of  time,  by  the  continuous  intravenous  infusion  of 
adrenalin  in  salt  solution,  1  in  50,000  to  100,000.  A  decapi- 
tated dog  was  kept  alive  ten  and  a  half  hours  in  this  way.  By 
increasing  the  surrounding  atmospheric  pressure,  in  a  pneu- 
matic chamber  or  tube,  the  arterial  pressure  could  be  con- 
trolled at  will,  and  paralleled  the  movements  of  external 
pressure.  This  prompt  response  of  the  blood-pressure,  when 
suflicient  peripheral  resistance  was  supplied,  proved  conclu- 
sively that  the  heart  was  not  at  fault ;  just  as  in  Romberg  and 
Passler's  experiments,  ligature  of  the  aorta  demonstrated  the 
functional  capacity  of  the  heart  in  the  collapse  of  acute  dis- 
ease. On  the  other  hand,  the  complete  abolition  of  the  reflex 
rise  in  pressure,  and  of  a  rise  from  central  stimulation  with 
strychnin,  while  adrenalin  produced  normal  vaso-constriction, 
showed  that  central  vaso-motor  paralysis  was  the 
real    cause    of   the   hypotension. 

Porter  and  Quinby  have  recently  interposed  some  objec- 
tions to  the  theory  that  exhaustion  of  the  vaso-constrictor 
centre,  or  neurons,  is  the  essential  cause  of  shock.  These  rest 
upon  a  few  experiments,  in  which  they  proved  that  stimulation 
of  the  central  end  of  the  depressor  nerve  produced  the  same 
percentage  fall  in  blood-pressure,  in  rabbits  and  cats,  after  shock 
had  been  induced,  as  in  their  normal  state.     As  one  of  their 


LOW   BLOOD-PRESSURE  159 

protocols  shows  an  identical  result  after  section  of  the  dorsal 
cord,  which  eliminates  the  medullary  centre  entirely,  I  am  un- 
able to  follow  their  reasoning.  I  cannot  see  that  they  have 
eliminated  a  vagus  depression  of  the  heart,  which  Crile  found 
was  not  at  all  diminished  in  shock.  Neither  do  they  indicate 
the  depth  of  shock  produced. 

A  rapid  fall  in  blood-pressure  during  operation,  due  to 
haemorrhage  or  other  causes,  in  which  the  vaso-motor  centre 
has  not  become  exhausted  and  will  still  respond  to  peripheral 
or  central  stimuli,  is  called  collapse.  Between  it  and  shock, 
Crile  draws  a  sharp  line.  I  am  unable  to  see  that  the  distinc- 
tion is  more  than  one  of  degree,  but  it  unquestionably  justifies 
Crile's  methods  of  treatment  in  the  profound  cases.  This  will 
be  discussed  in  more  detail  in  the  chapter  relating  to  blood- 
pressure  in  surgical  conditions. 

c.  Practical  Results. — In  the  light  of  all  this  evidence,  I 
think  we  must  regard  collapse  and  shock,  whether  seen  medi- 
cally or  surgically,  primarily  as  disturbances  of  the  functions 
of  the  vaso-motor  centres.  Both  for  prognosis,  and  as  a  guide 
to  treatment,  therefore,  the  sphygmomanometer  becomes  valu- 
able. It  alone  can  give  warning  of  the  onset  of  the  hypoten- 
sion, which  accompanies  vaso-motor  paralysis.  Crile's  me- 
chanical support  of  the  circulation  by  a  pneumatic  suit  is  the 
direct  outcome  of  his  blood-pressure  researches,  and  promises 
much  in  the  treatment  of  operative  shock.  In  acute  disease, 
far  too  little  use  has  been  made  of  blood-pressure  observations 
to  control  treatment.  The  only  careful  work  along  these  lines 
has  been  that  of  Cook,  and  of  Cook  and  Briggs.  Their  results 
are  so  encouraging  that  blood-pressure  charts  should  become 
common,  at  least  in  hospitals.  In  private  practice  I  have 
found  that  an  intelligent  nurse  can  easily  make  the  necessary 
systematic  observations  on  these  cases. 

C.  Effects  and  Dangers  of  Hypotension. — Abnormally  low 
blood-pressure  must  lead  to  an  accumulation  of  blood  in  the 
veins  and  a  slowing  of  the  current  in  the  arteries,  if  it  be  pro- 
gressive. This  will  of  course  affect  the  capillary  circulation, 
and  the  nutritive  and  secretory  processes  dependent  on  it. 
The  great  accumulation  of  blood  in  the  abdominal  veins,  which 
results  from  extreme  loss  of  vaso-motor  tone,  naturally  affects 
the  blood  distribution  markedly,  and  lessens  the  amount  of  heat 


160  THE  BLOOD-PRESSURE   IN   DISEASE 

given  off  from  the  surface  of  the  body,  thus  increasing  fever. 
Most  serious,  however,  is  the  danger  to  the  heart.  Both  in 
physiological  experiment  (see  page  18),  and  in  pathological, 
we  have  found  that  complete  loss  of  vaso-motor  tone  soon  leads 
to  death,  because  the  ventricles  discharge  their  contents  into 
the  flaccid  arteries,  and  receive  less  and  less  blood  from  the  re- 
laxed veins.  The  diminished  energy  of  contraction  with  dimin- 
ished ventricular  contents,  which  Frank  demonstrated  (see 
page  15),  completes  the  vicious  circle.  Pal's  observations  of 
the  empty  ventricles,  found  at  autopsy  in  persons  dying  of 
phosphorus  poisoning,  are  the  pathological  evidence  of  this 
mode  of  death. 

4.    THE    RELATION    OF    BLOOD-PRESSURE    TO 
PULSE-RATE  AND    TEMPERATURE 

Marey  used  to  teach  that  arterial  pressure  and  pulse-rate 
varied  inversely  to  one  another  and,  in  fever  especially,  that 
higher  temperature  and  more  rapid  pulse  went  hand  in  hand 
with  diminished  pressure.  His  reasons  for  this  were  in  part 
sphygmographic,  in  part  theoretical.  The  older  clinical  state- 
ments, from  the  evidence  of  the  less  accurate  instruments, 
were  usually  positively  for  or  against  Marey's  teaching.  Wet- 
zel, and  Reichmann  believed  a  fall  to  be  the  rule  in  fever,  Zadek, 
and  Arnheim  taking  the  contrary  view  and  claiming  a  rise. 
Giglioli  thinks  the  relation  is  usually  an  inverse  one,.  Mosen, 
and  Kuhe-Wiegand,  however,  among  the  older  writers,  and 
more  recently  Alezais  and  Francois,  Hensen,  and  many 
others,  have  demonstrated  that  the  real  reason  for  such  mu- 
tually conflicting  opinions  lies  in  the  absence  of  any  definite 
relation  between  the  blood-pressure  and  the  temperature.  Po- 
tain  looks  on  the  infection  as  the  cause  of  the  lowering  of  pres- 
sure usual  throughout  acute  febrile  diseases.  He  sees  in  the 
fever  itself  an  influence  for  elevation,  which  makes  itself  felt 
in  the  lesser  rises  and  falls  from  hour  to  hour. 

As  a  matter  of  fact,  the  blood-pressure  in  febrile  disease  is 
sul)ject  to  many  of  the  causes  for  variation  Avhich  exist  during 
health,  in  addition  to  many  more.  In  consequence,  no  attempt 
to  explain  the  smaller  features  of  the  pressure  curve,  under 
such  circumstances,  can  hope  to  be  successful.     The  findings 


BLOOD-PRESSURE  AS   A   GUIDE  161 

of  Romberg  and  Passler,  in  the  early  stage  of  experimental  in- 
fections, show  that  fever,  of  itself,  is  inefficient  to  alter  mean 
blood-pressure.  That  says  nothing  as  to  possible  changes  in 
the  relation  of  systolic  and  diastolic  pressures  to  one  another. 
It  is  to  be  hoped  that  a  study  of  this  in  fever,  as  in  other  con- 
ditions, may  give  us  new  insight  into  the  circulatory  changes 
which  are  certainly  associated  with  the  temperature  changes. 
The  dicrotic  pulse,  for  instance,  may  find  more  satisfactory 
elucidation  in  this  way.  I  have  evidence  that  it  is  not  neces- 
sarily associated  with  low  systolic  pressure.  In  one  case  the 
pulse-pressure  variation  was  abnormally  increased,  as  would 
be  expected. 

5.  BLOOD-PRESSURE  AS  A  GUIDE  TO  THE  FUNC- 
TIONAL ABILITY  OF  THE  HEART  AND  THE 
ADEQUACY  OF  THE  CIRCULATION 

Strangely  though  it  sounds,  the  mean  blood-pressure  alone 
tells  us  absolutely  nothing  of  the  heart's  ability  to  carry  on 
the  circulation.  Clinically,  normal  and  even  somewhat  high 
tension  may  be  observed  in  patients  dying  of  slow  cardiac  fail- 
ure. On  the  other  hand,  animal  experiments  have  shown  that 
fatal  hypotension  occurs  with  a  heart  abundantly  able  to  main- 
tain a  high-pressure,  if  it  were  supplied  with  a  sufficient 
peripheral  resistance.  The  explanation  is  simple,  when  one 
remembers  the  reciprocal  relations  of  heart  and  vaso-motor 
system.  A  very  small  amount  of  blood  may  enter  the  aorta 
at  each  systole,  but  if  the  arterioles  be  so  tightly  contracted 
that  only  a  similar  amount  can  escape  into  the  capillaries,  the 
aortic  pressure  will  be  unchanged.  In  such  a  case  the  systolic 
and  diastolic  variation  will  be  slight.  On  the  other  hand, 
even  though  the  heart  deliver  five  times  the  normal  output  in 
a  minute,  if  the  arteries  are  so  dilated  that  six  times  the  usual 
quantity  passes  on  into  capillaries  and  veins,  the  aortic  pres- 
sure will  rapidly  fall.  Here  the  pulse-pressure  change  will  be 
large,  the  diastolic  pressure  very  low,  and  the  systolic  perhaps 
normal.  It  is  therefore  evident  that  the  measurement  of  the 
two  pressures  will  give  us  much  more  information  about  the 
actual  state  of  the  circulation  than  either  alone,  or  than  the 
mean  pressure,  because  affording  some  little  insight  into  the 
12 


162  THE   BLOOD-PRESSURE   IN   DISEASE 

systolic  pulse-volume  of  the  left  ventricle.  Erlanger  and 
Hooker  believe  that,  under  perfectly  normal  conditions,  the 
pulse-pressure  (difference  between  diastolic  and  systolic  pres- 
sure) varies  directl}"  with  the  acceleration  of  blood-flow  pro- 
duced by  each  pulse-wave. 

In  pathological  conditions  there  are  too  many  possible  vari- 
ables to  justify  such  an  opinion.  When  the  distensibility  of 
the  arterial  walls  is  diminished  by  disease,  or  more  especially 
by  high  internal  tension  (see  page  25),  a  small  amount  of 
blood  injected  into  the  aorta  will  raise  systolic  pressure  far 
more  than  an  equal  amount  at  lower  pressure.  This  does  not 
at  all  indicate  a  corresponding  augmentation  of  blood-flow. 
As  a  matter  of  fact,  though  changes  in  the  work  of  the  heart 
through  variations  in  aortic  pressure  are  marked,  the  effect  of 
output  variations  greatly  outweighs  them.  Zunst  has  shown 
that  the  heart  is  in  a  position  to  multiply  its  work  fivefold  in 
an  instant,  to  supply  the  blood  needed  for  ordinary  muscular 
activity.  The  possible  maximum  volume  increase  is  much 
larger.  In  comparison  with  such  figures,  even  a  doubling  of 
mean  aortic  pressure  looks  trifling.  Therefore,  with  the  chief 
factor  in  the  heart's  work  unmeasurable,  we  should  be  chary  of 
our  deductions  from  a  known  factor  of  secondary  importance. 

Here,  as  everywhere  in  medicine,  we  must  correlate  all  the 
evidence,  of  which  the  reading  of  the  sphygmomanometer  is 
but  part.  A  heart  may  be  carrying  on  the  circulation  normally 
in  bed,  but  be  inadequate  to  supply  the  demands  of  active  life. 
Blood-pressure  determinations  during  exertion,  as  made  by 
Moritz,  might  give  light  on  this,  but  the  subjective  evidence 
of  dyspnoea  and  precordial  distress  are  more  readily  at  hand. 
Again,  with  hypotension,  the  heart  may  be  maintaining  the 
circulation  with  all  its  reserve  force,  or  with  only  its  ordinary 
expenditure  of  energy ;  no  measurements  can  tell  us  which. 

We  may  at  least  feel  sure  that,  with  normal 
or  high  pressure,  the  absence  of  dyspnoea  or  dis- 
tress on  exertion  argues  perfect  cardiac  func- 
tion at  the  time;  also  that,  with  low  pressure, 
the  clinical  evidence  of  a  disturbed  circulation 
may  coexist  with  a  sound  heart.  In  either  case 
we  obtain  more  conclusive  evidence  concerning 
the    peripheral    resistance.     This  has   more  than 


LITERATURE  163 

diagnostic  and  prognostic  value.  It  may  guide 
us  to  recognizing  the  necessity  for  attacking 
the  circulation  through  the  vaso- motor  system, 
when  this  is  at  fault,  and  thus  protect  the  heart 
from  secondary  damage,  and  needless  or  harm- 
ful  stimulation. 


LITERATURE 

Adami,  J.  G.  Notes  upon  Cardiac  Hypertrophy.  Montreal  Med.  Jotir., 
1895,  vol.  xxiil,  p.  811. 

Alezais  et  Francois.  La  tension  arterielle  dans  la  fievre  typhoide.  Rev. 
de  Med.,  1899,  vol.  xix,  p.  88. 

Arnhein,  Fr.  Ueber  das  Verhalten  des  Warmeverlustes,  der  Hautperspi- 
ration  und  des  Blutdrucks  bei  verschiedenen  fieberhaften  Krank- 
heiten.     Zeitschr.  f.  klin.  Med.,  1882,  vol.  v,  p.  363. 

Askanazy,  S.  Ueber  den  Wassergehalt  des  Blutes  bei  Kreislaufstorungen, 
Nephritiden,  Anamien  und  Fieber,  etc.  Deutsch.  Arch.  f.  klin.  Med., 
1897,  vol.  lix,  p.  385. 

V.  Bamberger,  H.  Ueber  Morbus  Brightii  und  seine  Bezieliungen  zu 
anderen  Kranklieiten.  Volkmann's  Sammlung  klin.  Vortrage,  1879, 
vol.  clxxiii,  p.  1552. 

V.  Bascli,  S.     Die  Herzkrankheiten  bei  Arteriosclerose.     Berlin,  1901. 

Bright,  E.  Cases  and  Observations  Illustrative  of  Renal  Disease  Ac- 
companied with  the  Secretion  of  Albuminous  Urine.  Guy's  Hosp. 
Reports,  1836,  vol.  i,  p.  335  (see  p.  396). 

Cohnheim,  J.     Allgem.  Pathol.,  1880,  pp.  320-365. 

Ueber  acutes  Lungenoedem.     Gesam.  Abhandlungen,  Berlin,   1885, 

p.  593. 

Cook,  H.  W.  The  Clinical  Value  of  Blood -pressure  Determinations  as  a 
Guide  to  Stimulation  in  Sick  Children.  Am.  Jour,  of  the  Med.  Sci., 
1903,  vol.  cxxv,  p.  433. 

Cook,  H.  W.,  and  Briggs,  J.  B.  Clinical  Observations  on  Blood-pres- 
sure.    Johns  Hopkins  Hosp.  Eep.,  1903,  vol.  xi,  p.  451. 

Gushing,  Harvey.  Some  Experimental  and  Clinical  Observations  Con- 
cerning States  of  Increased  Intracranial  Tension.  The  Miitterer 
Lecture  for  1901.     Am.  Jour,  of  the  Med.  Sci.,  1902,  cxxiv,  p.  375. 

The  Blood-pressure  Reaction  of  Acute  Cerebral  Compression,  Illus- 
trated by  Cases  of  Intracranial  Haemorrhage.  Am.  Jour,  of  the  Med. 
Sci.,  1903,  vol.  cxxv,  p.  1017. 

Crile,  G.  W.     Blood-pressure  in  Surgery.     Philadelphia,  1903. 

Erlanger,  J.,  and  Hooker,  D.  R.  The  Relation  between  Blood-pressure, 
Pulse -pressure  and  the  Velocity  of  Blood-flow  in  Man.  Am.  Jour, 
of  Physiol.,  1904,  vol.  x ;  Proceed,  of  Am.  Physiol.  Soc,  p.  xv. 


164  THE   BLOOD-PRESSURE   IN   DISEASE 

Giglioli,  G.  Y.     Alcuue  criticbe  e  alcune  ricberche  cli  sflgmomanometria 

clinica.     Eiv.  crit.  di  clin.  rued.,  1900,  vol.  i,  pp.  625  aud  611. 
Gull,  W.  W.,  and  Sutton,  H.  G.     On  the  Pathology  of  the  Morbid  State 

commonly  called  Chronic  Bright's  Disease  with  Conti'acted  Kidney. 

Medico-Cbirurg.  Transactions,  1872,  vol.  Iv,  p.  273. 
Hasenfeld,    Arthur.     Ueber    die    Herzhypertropbie     bei    Arteriosclerose 

nebst  Bemerkungen  iiber  die  Herzhypertrojjbie  bei  Schrumpfniere. 

Deutsch.  Arch.  f.  klin.  Med.,  1897,  vol.  lix,  p.  193. 
Hasenfeld  und  Fenyvessy.     Ueber  die  Leistungsfiihigkeit  des  fettig  en- 

tarteten  Herzens.     Berl.  klin.  Wochenschr.,  1899,  vol.  xxxvi,  pjx  80 

and  125. 
Hasenfeld  und  Komberg.     Ueber  die  Reservekraft  des  hypertrophischen 

Herzmuskels,  u.  s.  w.     Arch.  f.  exper.  Pathol,  u.  Pharmakol.,  1897, 

vol.  xxxix,  p.  331. 
Heineke,  H.     Exi^erimentelle  Untersuchungen  iiber  die  Todesursache  bei 

Perforationsperitonitis.     Deutsch.  Arch.  f.  klin.  Med.,  1901,  vol.  Ixix, 

p.  429. 
Hensen,  H.     BeitrJige  zur  Physiologie  und  Pathologic  des  Blutdrucks. 

Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol.  Ixvii,  p.  438. 
Hill,  Leonard.     The  Pliysiology  and  Pathology  of  the  Cerebral  Circula- 

lation.     London,  1896,  pp.  149  aud  following. 
Hirsch,  Carl.     Ueber  die  Beziehungen  zwisehen  dem  Herzmuskel  und 

der  Korpermuskulatur  und  fiber  sein  Verhalten   bei  Herzhypertro- 

l^hie.     Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol.  Ixviii,  p.  55. 
Hir.sch,  C. ,  und  Beck,  Carl.     Studien  zur  Lehre  von  der  Viscositiit  (in- 

neren  Reibung)  des  lebenden  menschlichen  Blutes.     Deutsch.  Arch. 

f.  klin.  Med.,  1902,  vol.  Ixxii,  p.  560. 
Huchard,  H.     Trait6  cliniques  des   maladies  du  cceur  et  des  vaisseaux. 

Paris,  1893. 
Israel,    O.     Experimentelle    Untersuchung    iiber    den    Zusammenhang 

zwisehen    Niereukrankheiten   und    secundi'iren    VerJinderungen     des 

Circulationssystems.       Virchow's     Arcliiv,     1881,     vol.     Ixxxvi,     p. 

299. 
John,  Max.     Ueber  den  arteriellen  Blutdruck  der  Phthisiker.     Zeitschr. 

f.  diiit.  u.  phys.  Therap.,  1902,  vol.  v,  p.  275. 
Johnson,  Sir  George.     The  Pathology  of  the  Contracted  Granular  Kid- 
ney.    London,  1896. 
Kapsamraer,  Geo.     Blutdruckmessungen  mit   dem  Gartner'schen  Tono- 
meter.    Wien.  klin.  Wochenschr.,  1899,  vol.  xii,  p.  1279. 
Kocher,    Th.      Hirnerschiitterung,     Hirndruck,    etc.     Nothnagel's  spec. 

Pathol,  u.  Therap.,  vol.  ix,  III.  Th.,  II.  Abth.,  Wien,  1901. 
Krohl,  L.     Pathologische  Physiologie.     Leipzig,  1898. 

Die  Erjcrankungen  des  Herzmuskels  und  die  nervosen   Herzkrank- 

ungen.     Nothnagel's  spec.  Pathol,  u.    Therap.,   vol.   xv,   1.    TIi.,  V. 

Abth.,  Wien,  1901. 


LITERATURE  165 

Kuhe-Wiogand,  H.     Ueber  den  Einfluss  des  Fiebers  aiif  den  arteriellen 

Blutdnick.     Arch.  f.  exp.  Pathol,  u.  Pharmakol.,  1886,  vol.  xx,  p.  12(j. 
Lewy,  Beuno.     Die  Arbeit  des  gesunden  und  des  kranken  Herz.     Zeit- 

schr.  f.  klin.  Med.,  1897,  vol.  xxxi,  pp.  321  and  520. 
Marey,  E.  J.     La  cii'culation  du  sang  a  I'etat  physiologique  et  dans  la 

maladies.     Paris,  1881,  pjo.  334  and  5G4. 
Moritz,  O.     Der  Blutdrack  bei  Korperarbeit  gesunder  und  Herzkranker 

Individuen.     Dexitsch.  Arch.  f.  klin.  Med.,  1903,  vol.  Ixxvii,  p.  339. 
Mosen,  R.     Ueber  das  Verhalten  des  Blutdrucks  in  Fieber.     Deutsch. 

Arch.  f.  klin.  Med.,  1894,  vol.  lii,  p.  600. 
Pal,   I.      Ueber    Gefiisstod.      Wien.    klin.   Eundschau,    1899,   vol.    xiii, 

p.  229. 
Piissler  und  Kolly.     Experimentelle   Untersuchtingen   iiber  Kreislaufs- 

storungen  bei  acuten  Infeetionskrankheiten.     Deutsch.  Arch.  f.  klin. 

Med.,  1903,  vol.  Ixxvii,  p.  96. 
Porter,  W.  T.,  and  Quinby,  W.   C.     The  Condition  of  the  Vaso-motor 

Neurons  in  "  Shock."    Boston  Med.  and  Surg.  Jour.,  1903,  vol.  cxlix, 

p.  455. 
The  Condition  of  the  Vaso-constrictor  Neurons  in  "  Shock."     Am. 

Jour,   of  Physiol.,    1904,   vol.    x.     Proceed,    of  Am.    Physiol.    Soc, 

p.  xii. 
Eeichmann,    Ed.     Ueber   das  Verhalten  des  arteriellen   Blutdruckes  in 

Fieber.     Deutsch.  med.  Wochenschr.,  1889,  vol.  xv,  p.  784. 
Eiegel,  Fr.     Ueber  die   Veranderungen   des   Herzens  und   des   Gefass- 

systems  bei  acuter  Nephritis.     Zeitschr.  f .  klin.  Med.,  1884,  vol.  vii, 

p.  260. 
Eolly,  F.     Ueber  die  "Wirkung  des  Diphtheriegiftes  auf  das  Herz.     Arch. 

f.  exp.  Pathol,  u.  Pharmakol.,  1899,  vol.  xlii,  p.  283. 
Eomberg,  E.,  und  Passler,  H.     Experimentelle  Untersuchungen  iiber  die 

allgemeine  Pathologie  und  Therapie  der  Kreislaufsstorung  bei  acuten 

Infeetionskrankheiten.     Deutsch.  Ai-ch.  f.  klin.  Med.,  1899,  vol.  Ixiv, 

p.  652. 
Eosenbach,  O.     Die  Krankheiten  des  Herzens.     Wien,  1897,  pp.  551-579 

and  742. 
Sansom,  A.  E.     The  Diagnosis  of  Diseases  of  the  Heart  and   Thoracic 

Aorta.     Philadelphia,  1892. 
Senator,  H.     Die  Erkrankungen  der  Nieren.     "Wien,  1902,  pp.  110-129. 
Sibson,  F.     The  Influence  of  Bright's  Disease :    (1)  On  the  Heart  and 

Arteries :    (2)    On   the   Production  of  Inflammation.     Lancet,  1874, 

vol.  i,  pp.  437  and  505. 
v.  Stejskal,  K.     Ivritisch-exiDerimentelle  Untersuchungen  iiber  den  Herz- 

tod   in  Folge  von  Diphtherietoxin.     Zeitschr.   f.   klin.   Med.,   1902, 

vol.  xliv,  p.  367;  and  1903,  vol.  li,  p.  129. 
Sumikawa,  P.     Ein  Beitrag  zur  Genese  der  Arteriosklerose.     Beitr.  zur 

pathol.  Anat.  u.  zur  allgem.  Pathol. ,  1903,  vol.  xxxiv,  p.  242. 


166  THE   BLOOD-PRESSURE   IN   DISEASE 

Traube,  L.    Gesam,  Abhandlungen.    Berlin,  1856,  vol.  ii,  p.  290;  vol,  iii, 

p.  440. 
Wetzel,  A.     Ueber  den  Blutdruck  im  Fieber,     Zeitschr.  f,  klin.  Med., 

1882,  vol.  V,  p.  323. 
Zunst,  N.     Die  Ernahrung  des  Herzens  und  ihre   Beziehung  zu  seiner 

Arbeitsleistung.     Deutsch.  med.  Wochenschr.,  1892,  vol.  xviii,  p.  109. 


CHAPTER  VII 

BLOOD-PRESSURE  IN  INTERNAL  DISEASES 

1.  Diseases  of  the  heart,  arteries,  and  kidneys. 

A.  ISTephritis. 

a.  Chronic  interstitial  nephritis. 

b.  Other  forms  of  chronic  nephritis. 

c.  Acute  nephritis. 

d.  Uraemia. 

B.  Cyclical  albuminuria. 

C.  Arterial  disease. 

a.  General. 

b.  Of  the  cerebral  vessels.     Apoplexy. 

c.  Other  local  processes.     Thrombosis;  aneurism;  compression 

D.  Diseases  of  the  heart-muscle. 

E.  Valvular  heart-lesions. 

a.  Aortic  insufficiency. 

b.  Other  valve-lesions. 

c.  Acute  endocarditis. 

F.  Neuroses  of  the  heart. 

a.  Exophthalmic  goitre. 

b.  Other  neuroses. 

G.  Prominent  cardiac  symptoms. 

a.  Angina  pectoris. 

b.  Cardiac  asthma  and  other  forms  of  dyspnoea. 

c.  The  arrhythmias. 

H.  Effects  of  exertion  on  blood-pressure  in  cardio-vascular 
disease. 

I.  Therapeutics. 

Literature. 

167 


108     BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

2.  Acute  infectious  diseases. 

A.  Typhoid  fever. 

a.  Haemorrhage  and  collapse. 

b.  Perforation, 

c.  Therapeutics. 

d.  Late  effects, 

B.  Pneumonia. 

C.  Diphtheria. 

D.  Other  acute  infections. 

Malaria;  acute  rheumatism  ;  septic  conditions ;  influenza. 

E.  Acute  infections  in  childhood. 
a.  Therapeutics. 

3.  Chronic  infectious  diseases. 

A.  Tuberculosis, 
a.  Haemoptysis. 

B,  Syphilis. 

4<  Chronic  diseases  associated  with  impaired  nutrition. 

A.  Diabetes, 

B.  The  anaemias. 

C.  Cachectic  states, 
a.  Addison's  disease. 

5.  Miscellaneous. 

A,  Lead  poisoning. 

B.  Gout. 

C  Emphj^sema,     Chronic  bronchitis.     Asthma, 

D.  Pleural  and  peritoneal  effusions. 

E.  Haemorrhage. 
Literature. 


CHAPTER  YII 

BLOOD-PRESSURE  IN  INTERNAL  DISEASES 

1.   DISEASES    OF   HEART,  ARTERIES,  AND  KIDNEYS 

The  tabulation  of  the  results  of  blood-pressure  observations, 
as  of  all  other  medical  statistics,  is  most  unsatisfactory  in  those 
conditions  which  least  readily  lend  themselves  to  a  uniform 
classification,  and  in  which  the  personal  equation  of  the  ob- 
server most  conspicuously  enters  into  the  diagnosis.  Acute 
diseases  are,  in  the  main,  easily  recognized,  and  are  always 
pla.ced  in  the  same  category.  Chronic  diseases,  however,  espe- 
cially those  which  involve  the  circulatory  system  and  kidneys, 
are  difficult  of  analysis,  even  at  the  post-mortem.  In  most 
instances  heart  and  arteries  are  both  involved  in  chronic  disease 
of  the  kidney,  and,  vice  versa,  many  primary  cardiac  lesions 
lead  in  time  to  renal  involvement.  Since  the  proper  classifica- 
tion of  these  cases  offers  such  difficulties  to  the  pathologist, 
what  wonder  that  their  clinical  diagnosis  should  be  so  largely 
a  matter  of  individual  opinion.  I  shall  therefore  at  the  outset 
ask  pardon  for  giving  my  own  observations  an  apparently  un- 
due weight  in  this  section,  because  they  are  the  only  ones  whose 
inherent  error  I  can  at  all  calculate. 

A.  Nephritis. — a.  Chronic  Interstitial  Nephritis. — The  clinical 
picture  of  "the  genuine  contracted  kidney"  of  the  Germans, 
' '  the  small  granular  kidney  "  of  the  English  writers,  is  in  most 
cases  sufficiently  clear-cut  to  make  the  diagnosis  during  life 
secure.  It  is  essentially  a  disease  of  kidneys,  arteries,  and 
heart  combined.  Permanent  high  blood-pressure  is  one  of  its 
salient  features,  higher  than  is  usually  seen  in  any  other  con- 
dition. Recent  sphygmanometric  observations  have  only  em- 
phasized this  already  well-known  fact.  A  S3"stolic  pressure  of 
more  than  200  mm.  (12  cm.),  240  mm.  (5  cm.),  is  not  uncom- 
mon. Diastolic  pressure  will  be  60  to  80  mm.  lower.  I  have 
seen  a  number  of  cases  that  gave  readings  over  300  mm.  (5  cm.), 

169 


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Blood  Pressure. 
Pulse  Rate. 

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s- 

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mm.  Hs.  90 

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No. per  mm. -y^ 

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60 
250 

40 
30 

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200 

90 
80 
70 
60 
150 

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,,,^ 

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___ 

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20 

10 

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80 
70 
60 
50 

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Fio.  42. 


Fig.  42. — Marked  hypertension  in  chronic  interstitial  nephritis. 
(Author's  and  Erlanger's  sphygm.    12  cm.) 

Chart  of  morning  and  evening  systolic  pressure  and  pulse-rate,  with  occasional  meas- 
urement of  diastolic  pressure,  from  S.  A.,  female,  aged  fifty-six,  City  Hospital. 

March  10th  ;  nose-bleed,  6  oz.,  for  which  large  doses  of  nitroglycerin  were  given  (see 
Fig.  52).    Note  the  lower  pressure  next  morning. 

March  10th  to  13th  ;  taking  nitroglycerin,  gr.  ^/loo,  q.  1  h. 

March  14th  to  16th ;  hot  pack,  b.  i.  d. 

March  17th  and  18th ;  taking  potassium  iodide,  gr.  x,  t.  i.  d. 

Note  the  absence  of  therapeutic  effect  on  the  average  level  of  blood-pressure. 

Observations  by  Dr.  W.  C.  Garvin, 


172     BLOOD-PRESSURE   IN  INTERNAL   DISEASES 

but  the  error  must  have  been  large.  The  highest  pressure  in 
chronic  nephritis  that  I  haA^e  met  with,  since  using  the  12  cm. 
armlet,  is  255  mm.  systolic,  180  mm.  diastohc. 

Cases  of  contracted  kidney  without  hypertension,  though 
very  rare,  do  occur.  Senator  calls  attention  to  the  fact  that 
cardiac  hypertrophy  may  fail  when  severe  wasting  disease  is 
present.  "When  seen  at  the  very  end  of  life,  in  hospital  prac- 
tice, the  pressure  may  not  be  high,  especially  if  the  heart  has 
become  insufficient.  The  same  cases  earher  would  probably 
have  shown  marked  hypertension.  Gross,  however,  reports  a 
case  in  which  small  kidneys  were  found  at  autopsy,  and  which 
was  under  observation -six  weeks,  with  pressures  between  120 
and  145  mm.  (R.  R.  5  cm.),  rising  to  only  IGO  mm.  during  a 
ursemic  seizure.  No  other  recent  observers,  of  whom  Butter- 
mann,  Carter,  Cook  and  Briggs,  Hensen,  Gumprecht,  Norris, 
and  Potain  give  especial  attention  to  nephritis,  report  an  un- 
doubted case  of  contracted  kidney  with  continued  low  pressures. 
Hensen  found  very  high  readings  even  when  advanced  phthisis 
was  also  present. 

Diagnostically,  hypertension  is  of  the  first  importance  in 
connection  with  the  contracted  kidney.  In  my  experience  it  is 
one  of  the  most  constant  and,  with  the  sphygmomanometer, 
most  easily  detected  evidences  of  the  disease.  The  enlarge- 
ment of  the  heart  requires  skill  to  make  out,  and,  with  obesity, 
baffles  the  expert.  The  urinary  changes  are  not  constant. 
Albumin  and  casts  are  frequently  absent,  and  even  quantity 
and  specific  gravity  may  be  normal  at  certain  periods.  A 
single  examination  in  office  practice  may  easily  fail  to  reveal 
anything  noticeably  abnormal.  The  great  advantage  of  routine 
blood-pressure  measurements  is,  that  hypertension  will  certainly 
be  detected.  While  not  a  pathognomonic  sign,  it  is,  neverthe- 
less, so  striking  that  it  puts  the  physician  at  once  on  the  alert. 
Given  a  systolic  pressure  of  over  200  mm.,  the  diagnosis  of 
contracted  kidney  must  be  disproved  by  repeated  examinations 
before  it  is  abandoned. 

The  most  striking  ilhastration  of  this  in  my  recollection  was  the  case 
of  a  priest  of  fifty-six,  who  consulted  my  father  on  account  of  three  epilep- 
tiform convulsions  which  had  come,  without  known  cause,  in  the  course 
of  six  months.  It  was  imijossible  to  prove  cardiac  hypertrophy.  The 
urine  showed  a  trace  of  albumin  and  a  few  hyaline  casts,  with  perfectly 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  173 

normal  quantity,  si^ecific  gravity,  and  urea  output.  The  question  was  be- 
tween true  epilepsy  and  ur;emic  convulsions.  The  blood-pressure,  which 
was  over  240  mm.  (E.  R.  5  cm.),  threw  the  scale  in  favor  of  their  uraemic 
nature.  Subsequent  examinations  showed  more  constant  urinary  changes, 
and  he  died  in  less  than  a  year. 

Patients  with  chronic  nephritis  frequently  consult  a  physician  for  nerv- 
ous symptoms,  for  headaches,  anginal  pain  on  exertion,  slight  dysi^noea, 
or  even  severe  cardiac  asthma,  and,  because  no  murmurs  are  present  and 
the  hypertrophy  is  overlooked,  they  are  assured  that  their  hearts  are  nor- 
mal. Such  mistakes  would  be  impossible  were  the  sphygmomanometer  in 
ordinary  use.  I  saw  the  other  day  a  lady  of  forty,  who  for  two  years  had 
had  considerable  shortness  of  breath  on  exertion.  At  times  she  also  suf- 
fered from  attacks  of  nocturnal  dyspnoea,  with  cough  and  raising  of  thin 
mucus,  sometimes  pink-tinged.  She  was  not  supposed  to  have  any  serious 
trouble.  On  account  of  her  stoutness  it  was  impossible  to  say  anything 
about  the  heart,  except  that  there  were  no  valvular  murmurs.  The  pulse 
tension  did  not  feel  extreme,  but  the  sphygmomanometer  showed  systolic 
255  mm.,  diastolic  180  mm.  (J.  12  cm.) ;  systolic  300  mm.  +  (R.  E.  5  cm.). 
Urine  examination  later  did  not  reveal  marked  change  in  quantity  or  spe- 
cific gravity,  but  there  was  a  fair  amount  of  albumin,  with  hyaline,  granu- 
lar, waxy,  and  fatty  casts.  She  was  evidently  having  mild  attacks  of  pul- 
monary oedema  at  night,  with  chronic  nephritis  and  a  left  heart  insuflScient 
for  the  demands  made  on  it  by  the  extreme  peripheral  resistance. 

Another  patient,  who  had  previously  considered  himself  in  perfect 
health,  consulted  a  physician  on  account.of  slight  disturbance  of  sensation 
and  motion  in  right  arm  and  leg,  Avhich  came  on  suddenly  with  a  transient 
aphasia.  He  had  been  twice  examined  when  I  saw  him ;  nothing  noted 
about  his  heart,  and  urine  not  looked  at.  He  had  marked  hyjjertension 
and  simple  hypertrophy  of  the  heart,  with  ringing  second  sounds.  It  was 
easy  to  predict  that  the  urine  would  probably  show  where  the  primary  dis- 
ease lay,  and  the  examination  showed  an  enormous  amount  of  albumin. 

Such  cases  could  be  multiplied,  but  the  lesson  they  have 
taught  me  is,  that  an  instrument  which  so  readily  gives  warn- 
ing of  the  existence  of  high  tension,  which  might  otherwise  be 
overlooked  during  hasty  examinations,  cannot  be  dispensed 
with.  Our  diagnostic  methods  are  not  yet  so  perfect  that  we 
can  afford  to  pass  by  any  reasonable  addition  to  them. 

In  the  primary  contracted  kidney  I  am  .unable  to  say  that 
any  definite  relation  exists  between  the  actual  height  of  blood- 
pressure  and  the  expectation  of  life.  One  patient  who,  three 
years  ago,  had  a  reading  above  300  mm.  (R.  R.  5  cm.,  to  be 
sure  on  an  enormous  arm),  is  in  as  good  condition  to-day.  A 
gradually  increasing  pressure,  which  resists  treatment,  is  of  bad 


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Fig.  43. — Chronic  nephritis;   left  hemiplegia;  lobar  pnetimonia  ;   death. 
(Author's  sphygm.  12  cm.) 

Chart  from  J.  F.,  aged  seventy-two,  male,  City  Hospital.  Old  hemiplegia  and  chronic 
nephritis ;  pneumonia,  right  lower  lobe,  beginning  March  20th,  with  high  temperature 
range. 

Autopsy  showed  gray  hepatization  of  right  lower  lobe  ;  marked  cardiac  hypertrophy 
(20  oz.) ;  general  and  cerebral  arterio-sclerosis ;  advanced  chronic  interstitial  nephritis ; 
areas  of  softening  in  each  lenticular  nucleus. 

Note  the  maintenance  of  extreme  hypertension  until  a  few  hours  before  death. 


176     BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

significance  when  there  are  any  symptoms  of  cardiac  insuffi- 
ciency, because  increasing  the  work  of  the  already  overtaxed 
left  ventricle. 

For  instance,  a  gentleman  of  past  fifty,  with  chronic  interstitial  neph- 
ritis and  a  much  hypertrophied  heart,  had  been  subject  to  anginal  attacks 
of  moderate  severity  on  exertion  for  several  years.  The  pain  came  be- 
neath the  sternum,  at  times  also  down  the  left  arm  to  wrist.  He  was 
formerly  able  to  attend  to  his  business  and  do  ordinary  slow  walking  with- 
out bringing  on  an  attack  oftener  than  every  few  weeks.  In  1901  his 
systolic  tension  was  230  mm.  (R.  R.  5  cm.).  In  January,  1903,  it  was 
270  mm.,  and  it  did  not  go  below  265  mm.  during  the  year;  diastolic  190 
to  200  mm.  (Erl.).  The  attacks  began  to  come  after  slighter  exertion,  in 
spite  of  the  continued  use  of  small  doses  of  potassium  iodide,  which  had 
always  acted  well  with  him  formerly.  By  the  latter  part  of  December 
systolic  pressure  rose  to  280  mm.,  and  attacks  were  repeated  several  times 
daily.  By  taking  nitroglycerin,  gr.  ji^  every  three  hours,  he  was  much 
better  for  a  time.  This  produced  a  fall  of  systolic  pressure  from  280  to 
255  mm.,  of  diastolic  from  180  to  160  mm.,  in  three  minutes.  Soon,  how- 
ever, the  pain  became  worse  again,  and  he  was  confined  to  his  house,  and 
was  not  seen  again.     He  died  in  April. 

Another  feature  in  prognosis  is  the  danger  of  cerebral  apo- 
plexy. Since  it  is  impossible  to  predicate  in  any  way  the  like- 
lihood of  local  arterial  disease  in  the  brain,  it  must  alwa5's  be 
considered  possible,  and  therefore  extreme  hypertension  makes 
one  fear  rupture. 

The  following  case,  among  many,  shows  such  a  termination,  and,  in 
addition,  the  history  is  of  interest  on  account  of  the  recurrence  of  severe 
attacks  of  oedema  of  the  lungs,  with  comparative  health  between.  The 
gentleman,  forty-four  years  of  age,  had  a  sudden  intense  attack  of  pul- 
monary oedema  at  night,  in  July,  1900.  This  came  without  warning,  lasted 
an  hour,  and  was  so  severe  that  he  lay  on  his  face  to  let  the  serum,  which 
he  raised  in  great  quantity,  run  out  of  his  mouth.  Between  that  time  and 
May,  1902,  he  had  three  severe  and  five  slighter  attacks  of  a  similar  kind. 
Beyond  slight  dyspnoea  on  exertion,  and  occasional  palpitation,  he  was  well 
between.  In  May,  1902,  he  showed  a  heart  coming  half  an  inch  beyond 
the  nipple  line,  with  booming  first  and  much  accentuated  aortic  second 
sound,  and  very  slight  aortic  diastolic  murmur.  The  arteries  were  some- 
what diffusely  thickened.  Arterial  pressure  was  240  mm.  (R.  R.  5  cm.,  arm 
thin).  The  urine  showed  increased  quantity  and  diminished  specific  grav- 
ity only.  In  June  he  had  five  attacks  in  seven  days,  after  which  he  im- 
proved. Urine  then  showed  a  faint  trace  of  albumin  for  the  first  time,  but 
no  casts.  Januaiy  17,  1903,  he  became  suddenly  unconscious  while  in  bed, 
showed  complete  left  hemiplegia,  and  died  in  not  much  more  than  five 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  177 

minutes.  At  autopsy,  Dr.  E.  H.  Kogers  found  a  large  lisemorrbage  in  the 
right  basal  ganglia,  but  not  breaking  through  into  the  ventricle.  Such 
a  termination  has,  of  course,  been  well  known  since  the  days  of  Bright. 

The  sudden  development  of  rising  pressure,  as  we  shall  see 
later,  may  indicate  the  onset  of  acute  ursemic  manifestations, 
and  deserves  immediate  attention.  I  believe  the  blood-pressure 
chart  as  essential  for  following  cases  of  renal  disease  as  is  the 
temperature  record  in  febrile  patients.  Figs.  42,  43,  and  44 
illustrate  this. 

b.  Other  Forms  of  Chronic  Nephritis. — Here  I  purposely  re- 
frain from  being  more  specific,  because  I  do  not  believe  the 
diagnosis  of  the  various  types  of  so-called  chronic  parenchym- 
atous or  diffuse  nephritis  can  be  made  accurately  during  life. 
In  none  of  them  is  high  arterial  pressure  so  constant  as  in  the 
chronic  interstitial  form.  In  amyloid  kidney,  cardiac  hyper- 
trophy regularly  fails,  and  Buttermann,  Hensen,  and  Hayaski 
report  cases  with  subnormal  pressures.  In  the  chronic  hsemor- 
rhagic  form,  normal  or  subnormal  readings  seem  frequent.  In 
typical  chronic  parenchymatous  or  diffuse  nephritis,  high  ten- 
sion may  be  as  marked  as  in  the  contracted  kidney. 

One  patient,  a  young  woman  of  twenty-seven,  has  had  abundant  low- 
gravity  urine,  loaded  with  albumin  and  casts,  for  nearly  five  years,  with 
some  oedema  of  the  legs  and  face  at  times.  A  year  ago  she  began  to  show 
well-marked  chronic  urtemia ;  vomiting,  weakness,  breathlessness,  and 
increasing  oedema,  and  anfemia.  She  also  developed  albuminuric  retinitis. 
Her  systolic  jDressure,  which  was  260  mm.  (R.  E.  5  cm.)  in  January,  in- 
creased to  270  mm.  in  March,  and  in  June  was  290  mm.  She  is  still  living, 
though  in  rather  precarious  condition.  In  all  probability  she  is  developing 
secondary  contraction. 

Another  case,  a  man  of  twenty-five,  had  severe  gonorrhoea  with  cys- 
titis four  years  before.  Two  years  later  he  develo^sed  headache  and  fre- 
quent urination,  and,  a  few  months  later,  oedema  of  face  and  pains  in 
back.  Nine  months  before  he  was  seen  he  had  both  kidneys  decapsu- 
lated  by  Edebohl's  method,  and,  since  operation,  had  suflfered  from  con- 
stant headache,  vomiting,  and  weakness,  and  had  become  very  anasmic. 
He  passed  65  to  80  oz.  of  urine  in  twenty-four  hours,  of  about  1,010  specific 
gravity,  containing  very  large  amounts  of  albumin,  and  hyaline,  granular, 
fatty,  and  epithelial  casts.  His  heart  was  not  enlarged  to  percussion,  but 
the  apex  first  sound  was  booming,  and  the  aortic  second  sound  was  accen- 
tuated.    Arterial  pressure  was  220  mm.  (E.  E.  5  cm.). 

On  the  other  hand,  a  man  of  fifty-three,  who  had  shown  albumin  in  the 
urine  and  oedema  of  the  legs  fifteen  years  before,  and  who  for  a  year  and 
13 


178    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

a  half  liad  not  been  free  from  some  oedema  and  albuminuria,  without  any 
heart  lesion,  showed,  only  two  months  before  death,  arterial  pressure  120 
to  130  mm.  (R.  R.  5  cm.). 

Such  a  case  cannot  be  classified,  but  shows  the  possibility  of  progres- 
sive fatal  nejDhritis  of  long  standing  without  high  tension.  In  the  milder 
forms  of  nephritis,  cardio-vascular  changes  may  not  develop.  Such  a  con- 
dition, for  instance,  is  shown  by  a  girl  of  thirteen,  who  had  acute  nephritis 
consecutive  to  diphtheria  at  three.  She  recovered  at  the  time,  but,  for  t  vo 
years  past,  albumin,  and  hyaline,  granular,  and  fatty  casts  had  appeared  in 
the  urine  frequently.  Beyond  a  slight  antemia  (haemoglobin  75  per  cent.), 
there  were  no  clinical  symptoms.  Her  systolic  pressure  was  105  mm., 
diastolic  85  mm.  (Erl.  5  cm.).  There  could  be  no  question  of  the  existence 
of  a  chronic  nephritis  in  spite  of  the  low  blood-pressure. 

In  the  diagnosis  of  these  forms  of  chronic  nephritis  the 
sphygmomanometer  gives  less  aid.  Hypertension,  if  present, 
is  additional  eA^dence,  and  points  to  the  existence  of  cardio- 
vascular changes,  with  their  attendant  dangers.  Its  absence, 
however,  in  no  way  negatives  the  diagnosis.  In  connection 
with  other  findings,  this  negative  evidence  may  be  accorded 
some  value,  especially  if  the  pressure  be  quite  low.  Such  cor- 
roborative testimony,  for  instance,  helps  in  deciding  whether 
an  albuminuria,,  which  behaves  in  other  regards  like  the  cyclic 
form,  can  be  considered  of  little  import,  or  is  an  early  sign  of 
real  inflammatory  kidney  disease. 

So  far  as  prognosis  goes,  as  a  rule  the  cases  of  nephritis, 
other  than  the  chronic  interstitial  variety,  have  seemed  more 
severe  when  associated  with  hypertension  and  cardio-vascular 
disease.  This  should  be  conditioned,  however,  as  applying  to 
cases  in  fair  nutrition  and  able  to  be  about.  Where  marked 
cardiac  insufficiency  or  other  complicating  disease,  such  as 
phthisis,  is  present,  low  pressure  may  go  hand  in  hand  with 
the  most  serious  outlook. 

c.  Acute  Nephritis. — The  term  acute  nephritis,  as  ordinarily 
met  with,  embraces  an  even  more  heterogeneous  group  of  con- 
ditions than  the  last.  Everything,  from  slight  cloudy  swelling 
to  the  most  intense  diffuse  inflammation,  may  be  included  under 
it.  One  would  scarcely  expect  the  mild  parenchj'matous  de- 
generations to  influence  blood-pressure.  Even  the  more  marked 
forms  of  secondary  acute  nephritis,  which  do  not  produce  symp- 
toms and  which  subside  with  the  primary  disease,  that  is,  the 
nephritis  which  usually  complicates  the  severe  cases  of  typhoid 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  179 

fever  and  pneumonia,  would  not  be  likely  to  have  hypertension 
when  they  give  no  other  evidence  of  circulatory  disturbance. 
Thus  we  find  Carter  stating  that  no  case  of  this  kind  he  exam- 
ined showed  high  pressure.  Buttermann,  also,  noted  an  ab- 
sence of  hypertension  in  mild  acute  nephritis,  and  in  one  case 
complicating  typhoid,  in  which  the  urine  showed  much  albu- 
min, blood,  and  casts.  Shaw  says  that  acute  kidney  disease 
does  not  appear  to  cause  increased  pressure  in  children.  I  have 
recently  seen  a  case  of  subacute  nephritis,  apparently  syphilitic 
in  origin,  showing  albuminuria,  with  epithelial,  blood,  waxy, 
granular,  and  hyaline  casts,  whose  pressure  was,  systolic 
105  mm.,  diastolic  85  mm.  (J.  12  cm.). 

On  the  other  hand,  Kaufmann  and  de  Bary  saw  moderate 
hypertension  in  five  cases  of  acute  diffuse  nephritis.  Butter- 
mann found  quite  high  readings  (210,  213,  193,  192  mm.  R.  R. 
5  cm.)  in  a  portion  of  his  cases.  One  patient  with  acute  scar- 
latinal nephritis  had  a  50  mm.  rise  within  twenty-four  hours 
from  the  onset  of  the  kidney  lesion.  In  his  cases,  the  pressure 
fell  with  the  disappearance  of  the  clinical  symptoms  of  renal 
disease.  The  older  observations  of  Traube,  Riegel,  and  others 
have  already  been  alluded  to.  They  make  it  clear  that  the 
nephritis  following  scarlet  fever  produces  a  rapid  rise  in  arte- 
rial pressure.  Sphygmomanometric  observations  on  this  form 
of  acute  Bright's  disease  are  urgently  needed,  and  should 
be  recorded  graphically  in  connection  with  the  pulse,  urine 
quantity,  cardiac  changes,  and  clinical  symptoms.  Such 
records,  with  autopsy  observations  and  careful  microscopic 
study  of  kidneys,  splanchnic  arterioles,  and  heart,  would  pos- 
sess great  value.  They  should  be  instituted  in  all  contagious 
hospitals. 

As  to  the  so-called  primary,  or  idiopathic  acute  nephritis,  I 
can  find  no  specific  data.  The  diagnosis  must  be  made  with 
great  caution.  In  hospitals,  so  far  as  my  experience  goes,  an 
acute  exacerbation  of  a  chronic  nephritis  is  the  condition  usu- 
ally called  primary  acute  nephritis.  In  such  cases  the  h3'per- 
tension  would  belong  with  the  chronic  process.  I  think  it 
probable  that  the  high  pressure  also  shows  an  exacerbation 
during  the  acute  symptoms. 

The  greatest  difficulty  in  the  way  of  satisfactory  determi- 
nations  during  acute  Bright's  is   the  oedema.      Even  slight 


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Fig.  44. — Chronic  uremia.     (Author's  sphygra.  12  cm.) 

Chart  from  J.  M.,  aged  forty-four,  male,  City  Hospital.  March  16th,  began  to  have 
an  exacerbation  of  a  chronic  nephritis,  after  an  attack  of  acute  gout ;  diminished  urine, 
oedema  of  face,  headache,  vomiting,  weakness.  Took  digitalis,  saline  diuretics,  hot  packs, 
and  nitroglycerin,  gr.  V50  q.  2.  h.,  without  effect. 

March  19th,  only  nitroglycerin,  gr.  V20  q.  2.  h.,  with  marked  reduction  of  tension, 
disappearance  of  headache,  and  general  improvement. 

After  March  21st  tension  rose  again  in  spite  of  medication,  falling  ten  days  later  with 
the  advent  of  another  acute  gouty  attack. 


182    BLOOD-PRESSURE   IN  INTERNAL  DISEASES 

grades  of  it  introduce  an  error,  and,  when  distinctly  appre- 
ciable, clinical  blood-pressure  measurements  are  impossible. 

d.  Uraemia. — It  is  difficult,  in  the  hterature  of  blood-pressure, 
to  distinguish  between  acute  and  chronic  uraemia.  Most  of  the 
observations  seem  to  bear  upon  the  latter  condition,  but  all  are 
of  real  interest.  There  seems  httle  question  that  the  uraemic 
manifestations,  that  is,  headache,  vomiting,  and  disturbances  of 
consciousness,  run  closely  parallel  with  the  blood-pressure. 
Fig.  44  is  a  clear  example  of  this.  Gross  cites  seven  cases 
with  continued  observations,  in  which  the  symptoms  increased 
■svith  the  tension  and  disappeared  with  its  reduction  through 
treatment,  except  that  in  the  fatal  cases  a  gradual  fall  in  pres- 
sure ushered  in  the  end.  Cook  and  Briggs,  in  their  Chart 
XVIII,  show  the  former  relation  in  a  striking  way,  and,  in 
Chart  XXIX,  fatal  hypotension  in  collapse  a  few  hours  before 
death  from  uraemic  coma.  Laqueur  first  called  attention  to 
this  important  prognostic  use  of  the  sphygmomanometer.  His 
cases  showed  a  rise  of  15  to  20  mm.  (G.)  every  time  the  S3^mp- 
toms  became  worse,  and  a  corresponding  fall  after  packs,  which 
had  a  beneficial  result.  The  terminal  fall  in  his  patients  began 
a  few  da3's  before  death,  and  was  attendant  upon  obvious  signs 
of  heart  weakness.  Pal  believes  that  headache  and  vertigo, 
transitory  focal  symptoms,  amaurosis  especially,  and  uncon- 
sciousness and  coma,  are  alike  dependent  on  high  tension  in  the 
cerebral  circulation.  The  first  two,  however,  are  frequently 
associated  with  conditions  of  cerebral  anaemia,  so  the  connec- 
tion seems  less  obvious,  though  still  perhaps  circulatory.  He 
is  convinced  of  the  great  prognostic  value  of  blood-pressure 
determinations  when  uraemia  is  feared. 

Ascoli,  in  his  book,  beUeves  that  uraemic  hypertension  is  an 
established  fact,  and  cites  a  most,  interesting  observation  of 
Forlanini  on  an  acute  uraemia  with  convulsive  seizures,  which 
I  think  merits  reproduction  in  detail  here. 

The  patient,  G.  M ,  a  man  of  forty-three,  was  admitted  to  the  clinic 
November  30,  1890,  with  headache,  dyspncta,  palpitation,  and  digestive 
disturbances,  which  had  developed  recently,  and  were  increasing.  He  had 
had  probable  acute  nephritis  seven  years  before,  cured  in  four  months. 
He  showed  marked  enlargement  of  the  heart,  with  accentuated  aortic 
second  sound,  but  no  murmurs.  The  pulse  was  frequent,  small,  and  tense. 
Arterial  pressure  250  to  270  mm.  (II.  R.  5  cm.).     Urine,  about  2,000  cc.  in 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  183 


tweuty-four  hours,  specific  gravity  1,010  to  1,012,  with  moderate  amounts 
of  aibuinin  and  fairly  normal  total  nitrogen.  On  a  milk  diet  and  potassium 
iodide  the  symptoms  remained  unaflfected  until  January  17,  1897,  when, 
after  only  slight  dizziness  and  chilliness  for  a  few  hours,  a  severe  convul- 
sion occurred.  The  following  table  shows  the  progress  of  the  case  to  the 
fatal  issue  five  and  a  half  hours  later. 


Blood- 

Time. 

pressure, 
mm.,  Hg. 

Pulse. 

Remarks. 

10.30 

314 

112 

The  ura3inic  attack  has  lasted  a  few  minutes. 
Complete  unconsciousness. 

.32 

320 

Clonic  convulsions,  especially  marked  in  right 
arm.     Sweating.     Narrow  pupils. 

.33 

334 

88 

.36 

•  .   . 

Venesection.    300  cc. 

.39 

294 

'86 

.41 

280 

80 

.42 

Venesection.    300  cc.  more. 

.46 

308 

'96 

.50 

315 

80 

.53 

318 

78 

.54 

309 

78 

Vomiting. 

11.03 

294 

62 

Vomiting ;  continued  unconsciousness. 

.07 

314 

60 

Sweating  has  ceased. 

.16 

316 

63 

Vomiting. 

.28 

318- 

60 

.33 

330 

57 

.35 

330 

60 

Slight  twitching  in  the  right  arm. 

.43 

Tonic  spasm  of  the  right  arm. 

.45 

350 

Clonic  spasms  of  the  upper  limbs. 

.46 

348 

General  convulsion  :  involuntary  micturition. 

.54 

128 

Irregular  pulse. 

.57 

350 

128 

The  general  convulsion  continues. 

12.02 

,  , 

Severe  general  convulsion. 

.04 

350 

60 

The  convulsions  are  increasing  in  severity. 

.09 

The  sphygmomanometric  observation  is  discon- 
tinued. The  patient  died  at  4  p.  m.,  after  a 
prolongation  of  the  ura3mic  condition. 

The  autopsy  revealed  a  great  hypertrophy  of  the  left  heart ;  myocar- 
dium and  valves  healthy;  hydropericardium,  but  no  other  dropsical  effu- 
sion ;  small,  fine-granular  kidneys,  with  adherent  capsule,  yellow  mottled 
surface,  much  contracted  cortex,  pale  medullary  substance.  The  anatom- 
ical diagnosis  was  contracted  kidney  with  acute  exacerbation,  concentric 
cardiac  hypertrophy,  hydropericardium. 

The  highest  tension  I  have  met  in  uraemia,  since  using  the 
13  cm.  cuff,  was  290  mm.,  a  day  before  death. 

B.  Cyclical  Albuminuria. — The  theory  has  been  frequently 
advanced  that  the  condition  known  as  cyclical  albuminuria,  or 
physiological  albuminuria,  is  dependent  on  altered  circulatory 


184  '  BLOOD-PRESSURE   IN   INTERNAL  DISEASES 

mechanics  in  the  kidney.  The  effect  of  posture  in  many  cases 
is  so  striking  that  the  name  "orthostatic  albuminuria"  has 
been  coined.  Two  recent  studies  with  the  sphygmomanometer 
lend  their  support  to  the  hypothesis.  Edel,  in  eight  cases, 
found  a  fall  in  pressure  under  conditions  which  ordinarily 
cause  a  rise  in  the  healthy  man;  viz.,  rising  from  bed,  and  cold 
baths.  Coincidently  with  this  fall,  albumin  appeared  in  the 
urine.  In  warm  baths  the  primary  rise  in  pressure  was  quickly 
succeeded  by  a  fall,  with  albuminuria,  and  the  same  occurred 
after  light  exercise.  He  believes  that  his  studies  indicate  the 
necessity  for  physical  training  and  similar  methods  of  treating 
the  unstable  circulation.  Erlanger  and  Hooker  made  a  careful 
study  of  the  relation  of  blood-pressure  and  the  pulse-pressures 
to  the  secretion  of  urine  and  albumin  in  one  case.  These  pres- 
sure determinations  with  Erlanger's  instrument  are,  of  course, 
accurate.  They  found  no  constant  relation  between  the  amount 
of  urine  and  albumin,  and  either  systolic  or  diastolic  pressure, 
or  pulse-rate.  They  did  prove,  however,  that  the  amount  of 
urine  increased  and  of  albumin  decreased  with  increase  in  the 
pressure  variation  of  the  pulse- wave.  Since  posture  has  a 
marked  influence  on  this  (see  page  IIG),  the  pulse-pressure 
being  greatest  in  the  recumbent  posture,  the  uniform  absence 
of  albuminuria  in  such  cases  during  rest  in  bed,  and  its  marked 
appearance  after  rising,  are  intelligible.  Albumin  excretion  is 
known  to  be  dependent  on  the  rate  of  blood-flow  through  the 
kidney,  the  relation  being  an  inverse  one.  These  observations 
easily  explain  its  variations  in  such  cases,  but  not  the  reason 
why  it  should  appear  at  all,  when  the  normal  man  does  not 
allow  it  to  pass  through  his  kidney  parenchyma.  Coupled 
with  Edel's  work  they  throw  new  light  on  a  rather  interesting 
condition,  and  are  valuable  chiefly  as  pointing  the  way  toward 
the  solution  of  some  clinical  problems  by  physiological  methods. 
C.  Arterial  Disease. — a.  General. — The  very  striking  relation 
between  the  distribution  of  the  arterio-sclerotic  process  and  the 
development  of  a  hypertrophied  left  ventricle,  which  Hasenfeld 
and  Hirsch  demonstrated  so  clearly  (see  page  143),  explains  the 
sphygmomanometric  findings  in  arterial  disease.  The  clinical 
diagnosis  of  arterio-sclerosis  usually  means  a  palpable  thicken- 
ing of  the  radial,  brachial,  or  temporal  arteries.  Sometimes 
even  the  sight  of  a  normally  tortuous,  l)ut  abnormally  exposed 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  185 

temporal,  is  considered  adequate  proof  of  disease.  At  the  best 
we  can  but  discover  sclerosis,  diffuse  or  nodular,  with  or  with- 
out marked  calcification,  of  the  larger  superficial  arteries,  by 
the  sense  of  touch.  In  elderly  persons  without  previous  rheu- 
matic history,  the  development  of  a  systolic  aortic  murmur,  or 
of  a  distinct  lesion  of  the  aortic  valves,  points  toward  atherom- 
atous changes  in  the  ascending  aorta.  Disease  of  the  retinal 
vessels  is  visible  through  the  ophthalmoscope,  and  from  it  we 
may  infer  similar  changes  in  the  cerebral  arteries.  Thus  only 
a  bare  fraction  of  the  arterial  tree  lies  within  reach  of  our 
methods  of  exploration,  and  the  most  important  branches, 
those  to  the  abdominal  viscera,  are  entirely  removed  from  ap- 
proach. The  sphygmomanometer  is  therefore  a  welcome  ad- 
junct to  our  other  means  of  examination.  In  my  experience 
and  that  of  most  others  (Carter,  Gumprecht,  Hensen,  Potain), 
a  considerable  degree  of  thickening  of  the  superficial  arteries 
may  coexist  with  pressure  not  above  the  normal.  In  hospital 
practice,  where  poor  nutrition  and  heart  weakness  complicate 
the  conditions,  even  low  normal  pressures  may  be  found.  It 
is  not  alone  the  nodular  form  of  arterio-sclerosis  which  fails  to 
raise  pressure.  I  have  seen  a  case  of  diffuse  thickening  of  the 
superficial  arteries  in  a  man  not  beyond  middle  life,  where  the 
reading  was  only  160  mm.  (R.  R.  5  cm.);  and  another  with 
systolic  140  mm.,  diastolic  about  115  mm.  (J.  12  cm.).  As  a 
rule,  however,  the  systolic  pressure  will  usually  be  somewhat 
above  normal,  160  to  180  mm.  (R.  R.  5  cm.),  145  to  160  mm. 
(12  cm.),  and  the  diastolic  very  little  raised,  110  to  130  mm. 
(5  cm.),  100  to  120  mm.  (12  cm.);  as,  for  instance,  a  man  of 
seventy,  with  extreme  calcification  of  brachials  and  radials,  and 
systolic  pressure  180  mm.,  diastolic  110  mm.  (Erl.  5  cm.).  Fig. 
45  shows  this  moderate  hypertension  and  its  variations  from 
day  to  day  during  an  acute  bronchitis. 

On  the  other  hand,  in  the  cases  of  general  arterio-sclerosis 
with  marked  hypertension,  chronic  Bright's  cannot  be  elimi- 
nated without  care.  The  combination  is  frequent,  and  gives 
the  highest  pressures  usually  met  with.  A  recent  case,  for 
instance,  had  systolic  240  mm.,  diastohc  160  mm.  (J.  12  cm.); 
with  the  5  cm.  cuff,  systolic  290  to  300  mm.,  diastohc  195  mm. 
Excluding  nephritis,  however,  there  are  fairly  numerous  cases 
showing  hypertrophied  hearts  with  high  arterial  pressure,  as  a 


AfQ>cA 

//       /5      /3       iH^       IS      Ho      n       1^ 

Blood  Pressure. 
Pulse  Rate. 

3^^ 

^ 

■^- 

^ 

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^4£ 

S~ 

0(0 

1 

1 

1 

J^ 

1. 

^^° 

? 

6^-2 

mm.  Hg.  90 

^il«=»      80 
No.permin.'Y^ 





1 

60 
250 

— 

— — 

40 
30 
20 
10 
200 

— 

90 
80 
70 
60 
150 

r""" 

. 

" 

" 

' 

^.Pc^O 

r" 

^^ 

^30 
20 
10 

Ix^tT^  100 

^ 

■in 

** 

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90 

-~m 

r-Lse    ^80 

70 
60 
50 

A 

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^ 

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/' 

V 

_._^ 

/ 

^^ 

s 

Jt^ 

>•• 

^ 

^ 

*«r 

*s 

^ 

40 
30 
20 
10 
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■ 



■ 

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Fig.  45. 


Fig.  45. — General  arterio-sclerosis.     (Author's  sphygm.  12  cm.) 

Chart  from  male,  aged  seventy,  with  marked  arterio-sclerosis,  general,  retinal,  and 
cerebral ;  cardiac  hypertrophy,  and  slight  chronic  nephritis ;  during  an  attack  of  acute 
bronchitis. 

Note  the  moderate  hypertension  and  moderate  increase  of  pulse-pressure. 


188    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

rule  with  evident  arterial  thickening,  but  sometimes  without. 
These  must  be  considered  as  having,  with  or  without  the 
changes  in  the  larger  arteries,  a  permanent  augmentation  of 
the  peripheral  resistance  in  the  smaller  arteries  and  arterioles, 
especially  in  the  splanchnic  circulation,  or  a  general  narrowing 
of  the  larger  visceral  arteries.  This  tallies  with  the  patholog- 
ical findings  quoted,  and  only  thus  can  the  absence  of  high 
pressure  in  the  ordinary  arterio-sclerosis  be  explained.  These 
cases  are  the  important  ones  practically,  and  their  recognition 
is  much  easier  by  the  sphygmomanometer  than  in  any  other 
way.  They  are  comparatively  infrequent  in  dispensary  and 
hospital  experience,  where  the  patients  do  not  apply  for  treat- 
ment until  late,  and  general  arterial  disease  and  chronic  neph- 
ritis usually  coincide.  Among  the  well-to-do  this  form  of 
cardio-vascular  disease  is  frequent  and  apparently  increasing. 
The  name  v.  Basch  proposes  for  it,  angio-sclerosis,  seems  to 
me  more  appropriate  than  Huchard's  designation,  presclerosis. 
V.  Basch's  elaborate  classification  into  pseudo-,  latent,  and 
manifest  angio-sclerosis,  and  manifest  arterio-sclerosis,  on  the 
basis  largely  of  the  state  of  the  blood-pressure,  I  think  goes 
beyond  the  facts.  He  neglects  wholly  the  possibility  of  pri- 
mary muscular  disease  of  the  heart,  with  arterial  changes  as 
a  later  complication;  and  certainly  arterio-sclerosis  in  all  its 
manifestations  cannot  be  looked  upon  as  a  later  development 
of  changes  in  the  arterioles.  His  manifest  cases,  which  show 
albumin  in  the  urine,  must  many  of  them  be  nephritics.  Never- 
theless he  has  done  a  great  service,  in  calling  attention  to  the 
fundamental  importance  of  the  blood-pressure  in  the  diagnosis 
and  management  of  diseases  of  the  arteries. 

To  illustrate  tlie  height  to  which  arterio-  or  angio-sclerosis,  with  cai'- 
diac  hypertrophy,  may  raise  blood-pressure  independently  of  any  kidney 
involvement,  I  will  cite  two  cases,  in  whom  chronic  Bright's  could  be  ex- 
cluded as  nearly  as  may  be  during  life.  One  gave  a  reading  for  systolic 
pressure  of  250  ram.,  diastolic  180  mm. ;  the  other,  systolic  240  mm.,  dias- 
tolic 160  mm.  (both  Erl.  5  cm.).  The  highest  figures  in  this  condition 
since  using  the  12  cm.  armlet  have  been,  systolic  205  mm.,  diastolic  135  mm. 
This  was  in  a  lady,  sixty-three  years  of  age.  Without  some  evidence  of 
arterial  thickening  I  have  not  met  a  case  above  systolic  190  mm.,  diastolic 
150  mm.  (Erl.  5  cm.).  The  patient  in  question  was  a  gentleman  of  forty- 
nine,  with  inherited  tendencies  to  vascular  disease,  who  for  a  few  months 
had  been  troubled  with  jialpitation  and  uncomfortable  consciousness  of 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  189 

his  heart,  but  who  showed  simply  the  moderately  high  tension,  very  slight 
enlargement  of  the  heart,  and  a  sharp  aortic  second  sound,  the  arteries 
being  imperceptible  when  empty. 

To  summarize,  we  may  say  that  arterio-sclerosis,  as  a  dis- 
ease of  the  larger  superficial  vessels,  is  without  marked 
influence  on  blood-pressure;  that  high  blood-pressure  argues 
involvement  of  the  small  arteries,  especially  in  the  splanchnic 
circulation,  and  that  such  cases  should  be  classed  in  a  separate 
category ;  that  in  all  cases  systolic  pressure  is  increased  much 
more  than  diastolic,  on  account  of  the  lessened  distensibility  of 
the  arterial  walls,  due  either  to  the  high  tension  or  to  the  dis- 
ease, or  both. 

b.  Of  the  Cerebral  Vessels ;  Apoplexy. — The  fact  that  cerebral 
arterial  disease  can  in  no  way  be  diagnosticated  from  the  gen- 
eral blood-pressure  has  already  been  mentioned  (see  page  143). 
Patients  with  the  most  extreme  general  arterio-sclerosis  may 
live  to  old  age  without  cerebral  accident,  and  others,  with  little 
disease  elsewhere,  die  of  apoplexy  in  middle  hfe.  As  a  rule, 
however,  cases  of  hemiplegia,  whether  due  to  thrombosis  or 
haemorrhage,  show  some  peripheral  sclerosis  and  moderate  ele- 
vation of  tension  (see  Figs.  43  and  62). 

Most  important  is  the  extreme  functional  hypertension 
which  large  intracerebral  haemorrhage  causes.  Cook  and 
Briggs,  and  Gushing  have  given  special  prominence  to  this. 
The  rise  thus  produced  was  up  to  350  and  400  mm.,  figures 
unapproached  in  any  other  condition.  Just  how  much  error 
their  narrow  armlet  introduced,  it  is  hard  to  say.  This  grade 
of  hypertension,  if  always  present,  would  serve  to  differentiate 
apoplectic  coma  from  any  other,  except  ursemic,  and  would 
count  somewhat  against  that.  I  have  not  seen  such  figures ; 
but  we  do  not  often  meet  the  acute  apoplexies  at  the  City  Hos- 
pital. Thrombotic  softening  is  the  common  cause  of  hemiplegia 
in  our  patients,  even  when  they  have  granular  kidneys  and 
high  blood-pressure.  Cook  and  Briggs,  and  Cushing,  both  lay 
stress  on  the  danger  of  hypotensive  medication  in  cerebral 
haemorrhage,  and  beheve  surgical  interference,  with  evacuation 
of  the  clot,  the  rational  treatment.  Further  discussion  will  be 
found  in  the  chapter  on  blood-pressure  in  nervous  diseases. 

c.  Other  Local  Processes — Thrombosis,  Aneurism,  Compression. — 
Thrombosis  of  a  subclavian,  axillary,  or  femoral  artery  is  rare, 


190    BLOOD -PRESSURE   IN   INTERNAL  DISEASES 

and,  when  present,  is  not  difficult  of  detection  by  the  finger.  The 
sphygmomanometer  may  be  helpful  in  incomplete  obstruction, 
or  in  following  the  progress  of  collateral  circulation,  by  meas- 
uring the  difference  of  pressure  in  the  two  extremities.  In  one 
patient  with  general  arterio-sclerosis  and  cardiac  hypertrophy, 
without  nephritis,  the  left  axillary  artery  became  completely 
obstructed,  with  disappearance  of  the  radial  pulse,  in  October. 
The  following  June  some  pulse  could  be  felt,  and  the  sphyg- 


P^io.  46. — Pulsus  differens.     Case  of  obstkuction   of  the  left  axillary  artery. 
(Jaquet's  sphygmograph.     Author's  sphygm.  12  cm.) 

A,  Tracing  from  right  radial.    Systolic  pressure,  205  mm.,  diastolic,  135  mm. 

B,  Tracing  from  left  radial.    Systolic  pressure,  about  105  mm. 


momanometer  showed:  right  arm,  systolic  pressure  190  mm., 
diastolic  135  mm. ;  left  arm,  sj^stolic  115  mm.,  diastolic  105  mm. 
(Erl.  5  cm.).  By  January  the  pulse  was  distinctly  fuller  and 
the  reading  was:  right  arm,  systolic  205  mm.,  diastolic  135  mm. ; 
left  arm,  systolic  145  mm.,  diastolic  not  obtainable  (J.  12  cm.) 
(see  Fig.  4(5,  taken  on  another  day). 

The  pulsus  differens,  occasionally  a  valuable  diagnostic  sign 
of  thoracic  aneurism,  may  be  detected  in  its  slighter  grades  in 
a  similar  way.  It  is  unwise,  however,  to  admit  differences  of 
less  than  20  mm.  as  evidence.     Apart  from  this,  the  finding  of 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  191 

hypertension  calls  attention  to  the  presence  of  general  or  vis- 
ceral arterial  disease,  or  chronic  nephritis,  as  well  as  the  local 
condition,  since  aneurism,  of  itself,  does  not  affect  general 
blood-pressure.  I  know  of  no  observations  on  femoral  pressure 
in  the  diagnosis  of  abdominal  aneurism,  but  it  might  be  ex- 
pected to  show  a  diminution,  compared  with  readings  from  the 
brachial.  A  wide  armlet  would  be  essential  for  this  purpose. 
Similarly,  local  aneurisms,  axillary  or  brachial,  might  produce 
the  same  effects  as  the  partial  occlusion  of  the  artery  from 
other  causes. 

Ekgren  reports  an  interesting  observation  on  a  case  of 
mediastinal  tumor.  In  the  standing  position  systolic  blood- 
pressure  was  alike  in  the  two  arms,  but,  on  lying  down,  it  was 
invariably  60  to  70  mm.  lower  in  the  right  arm.  Autopsy 
showed  a  large  mediastinal  lympho-sarcoma,  involving  the 
right  lung,  but  movable  in  such  manner  as  to  compress  the 
main  branches  of  the  aorta  on  the  right  side,  when  the  body 
was  on  its  back. 

D.  Diseases  of  the  Heart-Muscle. — The  clinical  diagnosis  of 
muscular  heart  lesions  seems  more  influenced  by  prevailing 
fashions  than  that  of  almost  any  other  group  of  pathological 
conditions.  Not  long  ago  it  was  the  custom  to  diagnosticate 
"  fatty  heart "  in  all  patients  showing  cardiac  enlargement  with 
symptoms  of  insufficiency,  not  due  to  valve  defect  or  kidney 
disease.  Now  these  same  peojDle  are  usually  said  to  have 
"chronic  myocarditis."  I  have  seldom  seen  either  diagnosis 
strikingly  confirmed  at  autopsy,  though  the  latter  designation 
comes  nearer  the  truth.  Even  the  pathological  diagnosis  of  a 
heart-muscle  is  not  easy,  and  ordinary  stained  sections  are  of 
small  value.  My  personal  feeling  inclines  strongly  to  the  behef 
that  an  anatomical  diagnosis  in  these  cases  will  always  be  be- 
yond the  reach  of  clinical  investigation,  and  worth  little  when 
attained.  Roily,  Hasenfeld  and  Fenyvessy,  and  Passler  and 
Roily,  have  all  shown  experimentally  that  considerable  myo- 
cardial change  is  compatible  with  adequate  reserve  force  of  the 
heart.  On  the  other  hand,  our  present  methods  do  not  always 
reveal  histological  alteration  in  the  muscle  commensurate  with 
the  functional  disturbance,  in  fatal  cases  of  heart  disease. 

A  fairly  accurate  functional  diagnosis  is  not  only  possible, 
but  of  real  importance  for  prognosis  and  treatment.    A  knowl- 


192    BLOOD-PRESSURE   IN  INTERNAL   DISEASES 

edge  of  the  condition  of  the  blood-pressure  is  essential  to  it. 
With  the  sphygmomanometer,  the  cases  of  large  weak  heart 
that  seek  treatment  on  account  of  dyspnoea,  precordial  distress, 
cardiac  asthma,  oedema,  or  subjective  disturbances  of  rhythm, 
may  be  quite  sharply  divided  into  two  groups;  the  one  with 
distinct  hypertension,  the  other  without.  The  first  group  con- 
tains the  hearts  in  which  hypertrophy  is,  or  is  becoming,  insuf- 
ficient to  compensate  for  the  increased  peripheral  resistance. 
They  are,  therefore,  the  cases  secondary  to  kidnej^  disease, 
arterio-  or  angio-sclerosis,  or  are  cases  of  primary  myocardial 
disease  which  have  developed  Bright's  or  arterial  changes.  In 
the  second  are  the  primary  uncomplicated  forms  of  myocardial 
disease,  and  sometimes  the  terminal  stage  of  patients  who  ear- 
lier belonged  in  the  former  group,  v.  Basch  has  studied  the 
secondary  cases  exhaustively,  and  his  book  contains  much  that 
is  suggestive.  They  are  by  far  the  more  frequent  in  practice, 
and  the  importance  of  their  recognition  lies  in  the  prime  neces- 
sity^ for  treating  the  condition  back  of  the  hypertension. 

The  following  case  is  typical.  A  gentleman,  fifty  years  old,  of  excel- 
lent habits  (an  atyi^ical  feature),  had  noticed  slight  irregular  heart-action 
ten  years  pre\aous.  Eight  years  later  it  recurred,  with  shortness  of  breath, 
while  on  the  ocean.  A  year  later  he  had  dysjinoea  and  oppression  while 
crossing  the  Rocky  Mountains.  At  the  time  of  his  first  visit  he  had  suf- 
fered from  rapid,  ii-regular  heart  action,  and  considerable  dyspncea  on 
exertion  and  at  night.  His  heart  extended  one  inch  beyond  the  left  nipple 
line,  with  a  large  area  of  absolute  dulness.  At  the  aj^ex  there  was  gallop 
rhythm,  and  a  systolic  miu'mur,  which  was  heard  out  into  axilla  and  also 
upward  over  the  heart.  The  systolic  arterial  pressure  was  260  mm.  (R.  E. 
5  cm.),  with  a  large  arm.  Urine  showed  nothing  abnormal.  He  was  given 
advice  as  to  the  avoidance  of  all  sudden  or  forced  exertion,  moderation  in 
diet,  no  smoking,  etc.,  and  put  on  jiotassium  iodide,  gr.  v,  after  meals, 
and  strychnin,  gr.  ■^^,  before  meals ;  also  nitroglycerin,  gr.  ^-J^,  for  emer- 
gency use  in  attacks  of  dyspnoea.  Twelve  days  later  he  professed  himself 
feeling  perfectly  well,  but  the  heart  showed  no  change.  Systolic  i)ressure, 
230  to  240  mm.  Four  months  later  he  was  having  only  occasional  attacks 
of  precordial  distress  and  dyspnoea  at  night,  relieved  at  once  by  nitroglyc- 
erin. The  heart  dulness  now  came  only  to  the  nipple  line,  but  gallop 
rhythm  and  murmur  persisted.  Systolic  pressure,  220  to  230  mm.  Six 
months  later  he  was  able  to  walk  a  mile  with  perfect  comfort,  and  was 
about  his  country  i:)lace  on  his  feet  all  day.  The  heart  now  sliowed  no 
gallop  rhythm,  and  only  a  faint  apex  murmur  when  recumbent,  none 
standing.  The  systolic  pressure  was  225  mm.  He  had  taken  the  strychnin 
and  iodide  steadily  for  six  months. 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  193 

Two  months  after  this  he  was  still  well,  the  heart  showed  no  special 
change,  but  systolic  pressure  was  250  mm.,  diastolic  180  mm.  (Erl. 
5  cm.).  He  continued  well  until  fourteen  months  from  the  first  visit, 
when  he  was  caught  out  walking  in  a  severe  snow-storm.  Following  this 
he  had  repeated  nocturnal  attacks  of  moderate  oedema  of  the  lungs,  that 
is,  urgent  dysiDuoea,  with  rattling  in  chest,  terminating  in  loss  than  an 
hour  with  the  expectoration  of  copious  watery  secretion.  His  heart 
became  larger  again,  rate  100  to  108,  systolic  pressure  245  mm.  The 
legs  showed  a  little  oedema,  and  the  urine  contained  albumin  with 
hyaline  and  a  few  granular  casts.  There  was  then  evident  insufficiency  of 
the  right  ventricle  superadded.  He  was  put  on  infusion  of  digitali.s,  and 
the  iodide  and  strychnin  resumed,  with  nitroglycerin  for  emergencies  as 
before.  He  improved  somewhat,  but  did  not  regain  the  comparative  com- 
fort he  enjoyed  before  the  exertion  in  the  snow-storm  overstrained  his 
left  heart,  and  brought  on  the  secondary  insufficiency  of  the  right.  He 
died  after  four  months,  without  my  seeing  him  again. 

The  patients  with  primary  uncomphcated  cardiac  insuffi- 
ciency, whom  I  have  seen,  had  for  the  most  part  high  normal 
pressures,  135  to  145  mm.  (12  cm.),  150  to  190  mm.  (5  cm.), 
with  fairly  normal  pulse-pressure.  One  case  showed  systolic 
pressure  of  145  mm.,  with  diastolic  120  mm.  (J.  12  cm.),  but 
the  heart  was  rapid.  These  cases  without  hypertension  are 
more  prone  to  have  oedema  and  evidence  of  right  ventricular 
failure.  Some,  however,  have  anginal  pain  on  exertion.  I 
have  once  seen  very  low  normal  pressure  with  the  former 
symptoms,  which  was  persistent  after  marked  evidence  of  a 
weak  right  ventricle  had  disappeared. 

The  patient  was  a  very  active  man  of  fifty-seven,  who,  four  years  be- 
fore, had  had  a  left  hemiplegia,  from  which  he  made  a  complete  recoveiy. 
Two  months  before  he  was  first  seen  by  my  father,  he  was  suddenly  seized 
with  such  extreme  dyspnoea  that  he  thought  he  should  die.  He  fell  on 
the  floor,  was  found  with  very  feeble  pulse,  and  had  hyi^odermics  of  nitro- 
glycerin given  him.  For  a  month  he  was  in  bed  with  constant  orthopnoea, 
and  had  double  hydrothorax  and  oedema  of  the  legs.  The  heart  was  large, 
with  faint  sounds  and  no  murmurs.  In  spite  of  his  great  discomfort  he 
would  not  keep  absolutely  quiet ;  but  a  month  later  a  mild  attack  of  lobar 
pneumonia  enforced  bed,  and  his  improvement  began  then.  On  infusion 
of  digitalis  and  strychnin  he  made  rapid  gains,  and  after  a  month  was  able 
to  walk  two  miles. 

At  this  time  his  heart  was  moderately  enlarged,  but  not  readily  made 

out,  on  account  of  overlapping  lung.     The  left  border  seemed  just  beyond 

the  nipple  line.     The  sounds  at  the  apex  were  faint  and  in  gallop  rhythm. 

At  the  base  the  inilmonic  second  was  markedly  accentuated.     There  were 

14 


194    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

no  murmurs.  Lungs  showed  a  little  crackling  at  base.  No  fluid  in  chest, 
no  oedema  of  legs.  Five  months  later,  having  had  dyspnoea  on  exertion 
for  a  month,  since  becoming  involved  in  an  exciting  aflfair,  his  heart  was 
the  same,  and  systolic  pressure  135  mm.  (5  cm.).  He  was  put  on  digitalis 
and  stiychnin  again.  Now,  four  months  later,  he  is  in  fairly  good  condi- 
tion ;  no  cedema,  no  trouble  at  night,  but  dyspnoea  on  exertion.  He  has 
taken  no  care  of  himself,  and  is  carrying  heavy  resijonsibility.  His  heart 
now  comes  scarcely  to  the  nijjple  line.  There  are  no  murmurs.  The  lungs 
are  clear.  The  urine  contains  neither  albumin  nor  casts.  Systolic  pres- 
sure is  105  mm.,  diastolic  85  mm.  (J.  12  cm.);  systolic  135  mm.  (R.  K. 
5  cm.)  as  before.  This  was  evidently  a  j^rimaiy  insufficiency  of  the  left 
ventricle  jirei^onderantly,  with  secondary  weakness  of  the  right. 

Another  j^atient  of  fifty-one  has  had  an  enlarged  heart  for  eleven  years, 
without  murmurs,  except  when  it  becomes  more  dilated  and  develops  a 
temporary  mitral  murmur.  The  pulmonic  second  sound  is  always  ex- 
tremely accentuated,  the  action  markedly  irregular  and  usually  rapid. 
There  is  no  arterial  thickening,  and  no  urinary  change,  excei:)t  when  his 
right  heart  flags.  He  has  had  dysj^noea  on  exertion,  and  some  cyanosis, 
which  have  increased  of  late  years.  The  condition  originated  in  what  was 
probably  an  acute  myocarditis  in  a  rheumatic  attack.  During  the  eleven 
years  be  has  been  through  several  attacks  of  mild  pneumonia,  or  at  least 
pulmonaiy  congestion  with  fever ;  attacks  of  severe  bronchitis ;  and  one 
serious  time  of  acute  cardiac  insufficiency,  with  largent  dysjmoea,  oedema, 
hydrothorax,  congested  liver,  etc.,  two  years  ago.  He  has  taken  great  care 
of  himself  as  regards  exertion  and  excesses,  and  uses  digitalin,  or  infusion 
of  digitalis,  and  strychnin  in  small  doses  most  of  the  time.  His  systolic 
pressure,  for  the  largest  waves,  does  not  go  above  145  mm.,  with  the 
smaller  waves  about  20  mm.  lower;  diastolic  105  mm.  (J.  12  cm.). 

The  cases  of  angina  pectoris  will  be  considered  by  them- 
selves, as  well  as  the  measurement  of  the  volume  irregularity 
of  the  pulse,  so  common  in  these  patients. 

E.  Valvular  Heart-Disease. — a.  Aortic  Insufficiency. — Nowhere 
does  the  apparent  contradiction  between  results  obtained  with 
the  instruments  measuring  systolic,  and  those  measuring  dias- 
tolic pressure,  stand  OTit  more  clearly  than  in  what  one  reads 
about  aortic  insufficiency.  Thus  we  find  Giglioli,  using  the 
Riva-Rocci,  stating  that  the  pressure  is  high  in  compensated 
cases,  as* much  as  175  mm. ;  Hayaski,  with  both  Riva-Rocci 
and  Gartner's  tonometer,  finding  hypertension;  and  Vaguez, 
with  tonometer,  getting  readings  of  200  to  220  mm.  On  the 
other  side.  Carter  found  the  pressure  in  uncomplicated  aortic 
insufficiency  always  low,  80  to  85  mm. ;  but  he  worked  with 
the  Hill  and  Barnard  sphygmometer.     Both  are  correct  obser- 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  L95 

vations,  and  both  are  entirely  erroneous  and  misleading  state- 
ments, simply  because  there  has  been  little  knowledge  among 
chnicians  of  the  criteria  used  for  indirect  blood-pressure  deter- 
minations, and  all  findings  alike  have  been  published  as  obser- 
vations on  "blood-pressure."  Potain  went  even  further  wrong 
and  tried  to  explain  how,  after  all,  the  pulse  of  aortic  insuffi- 
cienc}^  did  not  have  the  characters  of  low  tension.  As  a  matter 
of  fact,  the  great  interest  of  using  the  sphygmomanometer  in 
a  case  of  aortic  insufficiency  is,  that  it  gives  a  numerical  value 
to  the  well-known  pulsus  celer,  which  expresses  perfectly  the 
mechanical  effect  of  the  lesion  on  the  systemic  arterial  circula- 
tion. Hensen  and  the  author  both  called  attention  to  this  some 
years  ago,  and  the  advent  of  clinical  instruments  which  deter- 
mine both  pressures  should  put  a  stop  to  the  confusion  that  has 
reigned.  The  actual  figures  found  are  striking.  One  sees  in 
average  cases  a  rise  in  pressure  with  each  pulse- wave  of  75  per 
cent,  of  the  original  diastolic  prsssure,  in  niore  extreme  lesions 
100  per  cent.  One  patient,  for  instance,  a  gentleman  of  sixty- 
five,  with  aortic  insufficiency  of  long  standing  and  practically 
no  aortic  second  sound,  I  have  measured  sixteen  times  in  six 
weeks,  with  my  sphygmomanometer  (12  cm.).  His  systolic 
pressure  has  varied  between  130  and  155  mm.,  diastolic  between 
GO  and  75  mm.,  and  pulse-pressure  between  65  and  85  mm. 
The  average  has  been,  systolic  145  mm.,  diastolic  08  mm.,  dif- 
ference 77  mm.,  an  average  pulse-pressure  113  per  cent,  of  the 
previous  diastolic  pressure  (see  Fig.  47).  This  is  the  largest 
difference  I  have  ever  seen  in  an  uncomplicated  case,  using  a 
trustworthy  method. 

Aortic  insufficiency  with  chronic  nephritis  or  arterio-sclero- 
sis  may  give  even  greater  values  for  the  pulse-pressure.  One 
man  with  an  extreme  lesion,  of  specific  origin,  with  general 
arterial  dilatation  and  chronic  Bright's,  who  suffered  from  an- 
ginal pain  on  slight  exertion,  had  a  systolic  pressure  of  220  mm., 
diastolic  90  mm.,  (Erl.  5  cm.),  difference  110  mm.,  equal  to 
122  per  cent,  of  the  diastolic  pressure.  The  same  patient, 
three  months  later,  with  dilated  right  heart  and  dropsy,  had  a 
systolic  pressure  of  270  mm.  This  shows  that,  in  cases  with 
nephritis  at  any  rate,  loss  of  compensation  is  not  invariably 
attended  by  a  fall  in  pressure.  More  interesting,  from  a  diag- 
nostic standpoint,  are  the  combined  valve-lesions,  in  which  the 


19G    BLOOD -PRESSURE   IN   INTERNAL   DISEASES 

important  problem  is  as  to  which  preponderates.  I  have  not 
examined  many  cases  of  this  kind,  but  all  have  shown  a  marked 
reduction  in  the  pulse-pressure.  One  patient  with  a  double 
aortic  lesion,  in  whom  the  systolic  murmur  was  unusually 
harsh  and  pronounced,  showed  systolic  pressure  115  to  120  mm. 


"Pe^l'y  ar  vj , 

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Fig.  47. — Aortic  insufficiency.     (Author's  sphygiii.  12  cm.) 

(!liart  from  inalu,  aged  sixty-five,  witli  extreme  aortic  insufficiency,  fairly  compen- 
sated.    All  observations  in  beil.  in  the  nmrning. 

Note  tiie  extreme  increase  of  pulse-pressure  and  the  variability  of  blood-pressure. 


(slight  irregularity),  diastolic  80  mm.  (J.  12  cm.),  j)ulse-pres- 
suro  -40  mm.,  ecpial  to  50  per  cent,  of  the  diastolic.  A  inan,  on 
the  other  hand,  with  double  murmur,  but  the  systolic  element 
softer,  had  a  systolic  pressure  200  mm.,  diastolic  100  mm.  (Erl. 
5  cm.),  pulse-pressure  100  mm.,  ecpial  to  100  per  cent,  of  the 
diastolic.  This  ability  to  measure  the  mechanical  effect  of  the 
leakage  on  the  pulse  seems  to  me  of  great  value  in  such  cases 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  107 

with  double  aortic  murmur,  for  the  extent  and  direction  of  car- 
diac enlargement  is  the  same  whether  stenosis  or  insufficiency 
preponderates.  The  systolic  aortic  murmur  is  usually  heard 
accompanying  aortic  leakage  murmurs,  but  only  in  a  few  cases 
indicates  an  actual  stenosis.  These  cases  I  believe  may  be 
picked  out  by  the  sphygmomanometer,  provided  one  excludes 
the  very  slight  defects,  and  the  cases  complicated  by  mitral 
lesions,  or  with  broken  compensation. 

Where  aortic  and  mitral  murmurs  coexist  the  evidence  is 
equally  valuable,  not  only  as  showing  which  is  the  chief  lesion, 
but  also  helping  to  distinguish  between  a  real  complicating 
mitral  stenosis  and  the  so-called  Flint  murmur.  The  smallest 
pulse-pressure  I  have  ever  seen  in  aortic  regurgitation  was  in 
a  woman,  forty -two  years  old,  who  for  four  years  had  had  a 
varying  amount  of  dyspnoea,  at  times  cough  and  bloody  expec- 
toration, and  a  little  oedema  of  the  feet,  all  pointing  to  mitral 
disease.  At  the  time,  she  was  about  and  in  good  condition. 
Physical  examination  revealed  a  heart  enlarged  both  right  and 
left,  with  a  slight  presystolic  thrill  and  short  presystolic  mur- 
mur at  the  apex,  and  a  blowing  aortic  diastolic  murmur  heard 
all  over  the  precordium.  The  aortic  second  sound  was  pre- 
served, the  pulmonic  accentuated,  especially  when  lying  down. 
The  pulse  was  small,  regular,  not  distinctly  a  pulsus  celer.  The 
sphygmomanometer  showed  systolic  pressure  115  mm.,  dia- 
stolic 95  mm.  (Erl.  5  cm.),  pulse-pressure  20  mm.,  equal  to 
21  per  cent,  of  the  diastolic.  Evidently  the  aortic  lesion,  in 
si^ite  of  the  loud  murmur,  was  insignificant.  To  contrast  with 
this,  a  young  man  with  double  aortic  and  mitral  systolic 
murmurs,  had  systolic  125  mm.,  diastolic  65  mm.  (J.  12  cm.), 
pulse-pressure  GO  mm.,  equal  to  92  per  cent,  of  the  diastolic 
pressure. 

The  effect  of  the  disturbance  of  compensation  on  blood- 
pressure  and  pulse-pressure  is  hard  to  discuss  with  positive 
conviction.  I  have  seen  both  remain  very  high  where  the 
heart  was  much  dilated,  and  severe  dyspnoea  and  attacks  of 
cardiac  asthma  were  present.  Here  the  mitral  remained  suffi- 
cient. There  is  no  doubt  that  systolic  pressure  may  remain 
high  in  spite  of  marked  cardiac  insufficiency,  as  Hensen  and 
others  have  shown.  With  the  development  of  relative  mitral 
insufficiency,  one  would  expect  a  reduction  in  the  pulse-pres- 


198    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

sure,  but  fui'ther  studies  of  systolic  and  diastolic  pressures  are 
needed  to  clear  up  this  point. 

One  further  feature  of  the  blood-pressure  in  aortic  disease 
must  be  recorded,  namely,  its  variability  without  discoverable 
cause.  This  is  true  especially  of  the  systolic  pressure.  Hensen 
records  cases  where  fluctuations  of  40  mm.  occurred  in  a  few 
hours.  The  diastolic  pressure  maintains  a  more  constant  level. 
b.  Other  Valve-Lesions. — The  sphj-gmomanometer  is  peculiarly 
disappointing  in  valvular  heart-diseases  other  than  aortic  insuf- 
ficiency. We  have  already  seen  how  little  one  may  argue  from 
the  height  of  blood-pressure  as  to  the  work  of  the  heart  (see 
page  IGl).  There  is  a  general  consensus  of  opinion  that  the 
bulk  of  cardiac  cases  have  pressures  within  normal  limits, 
whether  the  measurements  be  of  systolic  or  diastolic  pressure 
(v.  Basch,  Potain,  Hensen,  Hayaski,  Norris,  Goldwater,  Car- 
ter, Jarotzny),  Studies  of  the  pulse-pressure  by  reasonably 
accurate  methods  are  as  yet  lacking.  I  have  found  it  as  low 
as  IG  per  cent,  of  the  diastolic  in  a  patient  with  aortic  stenosis 
and  mitral  insufficiency,  where  the  pulsus  tardus  was  very 
evident.  Also  in  mitral  stenosis,  especially  if  one  considers 
the  smaller  waves  rather  than  the  occasional  large  ones,  it  may 
be  much  diminished.  Accurate  measurements  are  scarcely 
possible  by  an  indirect  method,  when  so  much  irregularity 
exists  as  in  these  bad  mitral  oases.  One  woman,  for  instance, 
with  double  mitral  murmur  and  a  much  dilated  heart,  had  a 
diastolic  pressure  of  about  100  mm.,  with  systolic  for  the  small 
waves  105  mm.,  for  the  large  120  mm.  Here  there  was  a 
marked  reduction  of  the  pulse-pressure,  which  varied  between 
5  per  cent,  and  20  per  cent,  of  the  diastolic.  Nevertheless,  in 
another  patient  with  extreme  mitral  insufficiency  of  long  stand- 
ing, recovering  from  a  breakdown,  and  on  digitalis,  I  have 
repeatedly  found  systolic  pressure  IGO  to  165  mm.,  diastohc 
110  mm.,  pulse-i)rossuro  SOJmm.,  ecpial  to  45  per  cent,  of  the 
diastolic.  Further  observations  along  this  line  are  much  to  be 
desired. 

Concerning  the  effect  of  compensation  or  decompensation 
in  these  cases,  the  blood-pressure  seems  valueless,  at  least  when 
systolic  or  diastolic  pressure  alone  is  taken,  v.  Basch  long  ago 
called  attention  to  the  fact  that  systolic  i)ressure  may  even  rise 
when  cardiac  insufficiency  occurs.      Here  the  dyspnoea,  the 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  109 

renal  involvement,  the  mental  anxiety,  the  unnoticed  oedema, 
all  come  into  play.  The  psychical  state,  so  distressing  a  feature 
of  heart-disease  in  its  later  stages,  I  think  has  been  insufficiently 
emphasized  as  a  possible  factor  in  this  hypertension.  Studies 
of  the  effect  of  morphin,  which  so  often  acts  beneficially  under 
just  such  circumstances,  might  help  decide  its  importance.    The 


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4 . 

Fig.  48. — Terminal  hypotension  in  cardiac  disease. 

Chart  from  T.  B.,  aged  thirty-five,  male,  City  Hospital.  Old  mitral  insufficiency  and 
subacute  endocarditis  with  fever.     General  venous  congestion  and  o'dcma. 

Death  from  asystole,  heart  stopping  some  time  before  respiratimi  ceased. 

Note  the  parallel  movement  of  pressure  and  pulse.  Contrast  with  death  from  collapse 
(vaso-motor  death),  as  shown  in  Fig.  59. 


fact  that  hypertension  and  impending  cardiac  failure  may  co- 
exist, only  makes  it  more  evident  that  the  sphygmomanometer 
tells  us  far  more  of  peripheral  resistance  than  of  the  heart. 
Two  facts  must  be  borne  in  mind  in  reading  any  statistics  con- 
cerning valvular  lesions.  First :  Aortic  and  mitral  murmurs 
in  elderly  people  are  frequently  due  to  sclerotic  changes  in  the 


200    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

valves,  which  may  be  accompanied  by  similar  and  unnoticed 
arterial  lesions,  and  hypertension  be  dependent  on  the  latter. 
Second :  Mitral  insufficiency  is  so  commonly  due  to  a  dilatation 
of  the  mitral  ring  (muscular  or  relative  insufficiency),  that  many 
of  the  cases  reported  belong  with  the  muscular,  rather  than  with 
the  valvular  diseases.  Studies  in  un(iuestioned  simple  valve 
defects,  due  to  preceding  acute  rheumatic  endocarditis,  are 
needed,  before  we  can  conclude  that  blood-pressure  is  meaning- 
less in  valvular  heart-disease. 

c.  Acute  Endocarditis. — In  acute  endocarditis  the  only  records 
I  can  find  are  those  of  Shaw.  He  found  subnormal  pressures 
in  children  with  endocarditis  complicating  acute  rheumatism, 
as  low  as  80  mm.  (G.). 

F.  Cardiac  Neuroses. — a.  Exophthalmic  Goitre.— Arterial  pres- 
sure in  Graves's  disease  has  generally  been  considered  high  by 
those  who  used  the  sphygmomanometer.  Hensen,  Jackson, 
and  Gross  all  report  cases,  and  in  none  of  the  series  was  the 
systolic  pressure  low,  though  extreme  hypertension  (over 
200  mm.,  R.  R.  5  cm.)  did  not  occur.  My  own  observations 
have  coincided  with  this  view,  but  since  they  were  all  isolated 
and  not  repeated  determinations,  and  patients  with  this  disease 
are  exceedingly  nervous,  they  probably  contain  a  share  of 
psychical  hypertension.  The  recent  careful  studies  of  Spiethoff 
on  twenty  cases  with  the  Riva-Rocci  apparatus,  and  v.  Reck- 
linghausen armlet  for  comparison,  have  led  him  to  the  follow- 
ing conclusions : 

"  1 .  That  the  blood-pressure  shows  no  constant  change  in 
either  direction  in  Basedow's  disease ;  the  views  that  the  pres- 
sure is  always  raised,  or  that  it  is  always  lowered,  are  equally 
inadequate." 

"2.  Lowering  of  pressure  and  high  pressure  are  both  found 
in  the  severe  cases,  while  the  lighter  forms  do  not  vary  much 
from  the  normal." 

He  cannot  say  definitely  whether  the  heart  or  the  vaso- 
motor system  is  responsible  for  the  variation.  Neither  pressure 
nor  pulse-rate  were  satisfactory  indications  of  the  severity  of 
the  disease. 

Gross  calls  attention  to  the  great  lability  of  the  blood -pres- 
sure in  these  patients,  either  from  slight  mental  causes,  or 
apparently  spontaneously.     This  is  easily  comprehended,  when 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  201 

such  overirritability  of  the  whole  nervous  system  exists.  CHn- 
ical  observers  have  been  in  the  habit  of  considering  tension 
diminished  in  this  disease.  I  beheve  the  discrepancy  between 
this  and  the  usual  objective  determinations  finds  its  explana- 
tion in  the  same  cause  as  aortic  insufficiency — the  marked  ele- 
vation of  systolic  pressure  and  pulse-pressure,  diastolic  pressure 
not  rising  equally.  The  si^hyg-mographic  trace  obtained  in 
Graves's  disease  is  often  an  outspoken  pulsus  celer.  •  Unfortu- 
nately the  rapidity  of  the  pulse  and  the  muscular  tremor  make 
estimations  of  diastohc  pressure  verj^  difficult  in  these  people, 
and  I  can  only  record  a  single  satisfactory  one.  Here  the  sys- 
tolic pressure  was  200  mm.,  diastolic  130  mm.  (Erl.  5  cm.), 
pulse-pressure  70  mm.,  equal  to  54  per  cent,  of  the  diastohc. 
Were  all  the  pressures  corrected  for  the  narrow  armlet,  this 
would  be  about  65  per  cent.  In  this  case,  shght  perturbation 
ran  up  the  systolic  pressure  to  240  mm. 

b.  Other  Nervous  Disturbances. — The  classification  of  these 
obscure  conditions  is  unsatisfactory.  An5i:hing,  from  simple 
palpitation  in  young  girls  to  fatal  angina  pectoris  due  to  coro- 
nary thrombosis,  may  be  forced  into  the  category.  The  only 
work  relating  especiall)^  to  these  so-called  neuroses  is  that  of 
Hochhaus.  He  claims  to  have  found  high  pressures,  in  twenty 
men  150  to  210  mm.,  in  sixteen  women  140  to  210  mm.  (narrow 
armlet  of  course),  all  with  neuroses.  He  propounds  the  thesis 
that  hypertension  is  diagnostic  of  nervous,  as  against  organic 
affections  of  the  heart.  His  neuroses  were  either  sensory,  with 
precordial  oppression,  or  even  severe  anginal  j^ain,  as  its  evi- 
dence; or  motor,  with  tachycardia  or  arrhythmia. 

I  am  absolutely  unwilling  to  accept  his  conclusions.  His 
sensory  neuroses,  I  beheve,  all  belong  with  the  clinical  group 
of  myocardial  diseases,  in  which  hypertension  is  the  evidence 
of  permanent  changes  in  the  small  vessels.  Manj^  of  the  cases 
with  disturbance  of  rate  or  rhythm  also  belong  in  the  same 
category,  if  the  tension  was  high,  or  else  were  excited  when 
the  determination  was  made.  I  have  never  seen  a  case  of 
paroxysmal  tachycardia,  a  pure  neurosis,  if  there  be  such,  -vsath 
anything  but  normal  or  low  normal  pressure  between  the  at- 
tacks. During  attacks  I  have  made  few  observations,  but  they 
have  not  shown  hypertension.  As  to  the  arrhythmias,  they 
are  most  frequent  in  elderly  people,  where  one  always  suspects 


202    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

latent  angio-sclerosis.  Those  I  have  examined,  in  which  no 
proof  of  organic  disease  could  be  obtained,  had  pressures  below 
160  mm.  (R.  R.  5  cm.).  Hypertension  with  subjective  cardiac 
disturbance  is,  I  believe,  distinct  warning  of  the  onset  of  vas- 
cular disease. 

G.  Important  Cardio-vascular  Symptoms. — It  is  impossible  to 
consider,  within  a  reasonable  space,  the  relation  of  all  the 
clinical  features  of  cardio-vascular  disease  to  the  blood-pres- 
sure. Practically  all  of  them  are  due  rather  to  the  condition 
of  the  neuro-muscular  apparatus  of  the  heart  relative  to  the 
demands  upon  it,  than  to  the  absolute  amount  of  those  de- 
mands. The  chief  importance  of  a  knowledge  of  the  blood- 
pressure  in  connection  with  dyspnoea,  or  distress  on  exertion, 
or  other  evidence  of  heart  disturbance,  lies  in  its  testimony  as 
to  the  existence  of  an  unnecessarily  high  peripheral  resistance, 
which  may  be  combatted.  Angina  pectoris,  however,  is  a 
sj^mptom-complex  so  important  and  so  distinct,  that  it  deserves 
separate  consideration.  Some  definite  information  also  exists 
as  to  the  relation  of  certain  forms  of  dyspnosa  to  blood-pressure. 
Finally,  the  volume  irregularities  of  the  pulse  are  well  studied 
by  the  sphygmomanometer. 

a.  Angina  Pectoris. — A  certain  feeling  of  distress  or  pressure 
beneath  the  sternum  is  very  common  in  patients  with  marked 
essential  hypertension,  irrespective  of  the  primary  disease.  Few 
of  them  with  pressure  permanently  above  200  mm.  (12  cm.), 
220  to  240  mm.  (5  cm.),  can  even  walk  briskly  without  it.  This 
is  most  apt  to  come  with  exertion  following  a  meal,  and,  as 
belching  of  gas  is  a  frequent  accompaniment,  both  patient  and 
physician  commonly  put  the  blame  on  the  stomach.  In  more 
developed  form,  exercise  brings  a  feeling  of  intense  pressure 
across  the  ui)per  chest,  as  though  it  were  held  in  a  vice,  or 
there  is  a  pain  which  centres  there  and  radiates  to  the  left  or 
both  shoulders,  down  one  or  both  arms  to  elbow  or  wrist,  and 
up  the  neck  to  the  angle  of  the  jaw.  With  this  the  patient 
feels  compelled  to  stand  still,  and,  unless  the  attack  be  of  great 
severity,  the  sensations  pass  off  in  a  few  minutes  and  he  can 
walk  again.  The  worst  form  may  come  spontaneously,  espe- 
cially at  night,  as  well  as  after  effort  and  excitement,  is  of 
longer  duration,  and  associated  with  pallor  of  the  face  and 
great  mental  agony.     These  are  the  seizures  which  often  prove 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  203 

fatal.  Many  deny  the  name  of  angina  pectoris  to  the  Ughter 
attacks.  Nevertheless,  the  gradual  development  of  these  lesser 
feelings  of  tightness  or  distress  into  the  worst  pain,  which  one 
may  frequently  follow  during  the  course  of  years,  leaves  httle 
room  for  a  nomenclature  which  attempts  to  draw  a  sharp  line 
between  them.  Perhaps  the  designation  "  anginoid  "  describes 
the  minor  attacks  as  well  as  any. 

In  the  diagnosis  of  true  angina,  or  anginoid  attacks,  well- 
marked  hypertension  is  important  evidence.  Though  some 
cardiac  enlargement  and  a  systolic  aortic  murmur,  less  fre- 
quently a  mitral  murmur,  are  common  findings,  and,  in  con- 
nection with  the  patient's  account  of  his  sensations,  stamp  the 
attacks  as  really  of  this  nature;  yet,  in  a  certain  number,  no 
anatomical  change  is  discoverable  by  ordinary  physical  diag- 
nostic methods.  If,  then,  a  blood-pressure  of  over  ISO  mm. 
(12  cm.  or  G.),  200  mm.  (5  cm.),  be  found,  anginoid  pain  can 
be  held  due  to  definite  organic  disease.  The  negative  evidence 
is  not  so  convincing.  Especially  is  this  true  of  the  severe  at- 
tacks. I  have  seen  a  number  of  cases  of  true  angina  pectoris 
without  high  pressure,  that  is,  less  than  170  mm.  (R.  R.  5  cm.). 
Of  these  at  least  three  have  proved  fatal.  In  one,  who  died 
during  an  attack,  post-mortem  by  Dr.  Coplin,  of  Philadelphia, 
showed  chronic  myocarditis  with  enormous  increase  in  elastic 
tissue  throughout  the  heart.  There  were  no  cardiac  symptoms 
except  the  pain  on  exertion,  substernal  and  radiating  to  the  left 
shoulder  and  neck,  which  began  six  years  before.  No  physical 
signs  of  disease  were  present,  either  in  the  way  of  enlarged 
area  or  murmurs.  The  lowest  systohc  pressure  I  have  recorded 
in  this  condition  was  120  mm.  (R.  R.  5  cm.).  The  others  have 
varied  from  140  to  170  mm.  v.  Baech  notes  this  finding  of  low 
pressure  in  patients  with  anginal  symptoms,  which  he  has  seen 
in  eighteen  of  his  series,  forty-seven  having  had  tension  above 
the  normal.  During  the  attack  the  pressure  might  either  rise 
or  fall.  In  such  patients  the  diagnosis  and  prognosis  depend 
entirely  upon  the  character  of  the  attacks,  and  the  amount  of 
exertion  required  to  initiate  them.  With  intense  pain  regularly 
following  shght  exertion,  and  pallor  of  the  face  during  the 
attack,  a  low  blood-pressure  seems  to  argue  a  worse  outlook. 

Where  the  description  of  the  pain  is  atypical,  and  there 
seems  a  reasonable  question  of  its  being  a  neuralgia  or  a  reflex 


204    BLOOD-PRESSURE   IN   INTERNAL  DISEASES 

gastric  pain,  especially  when  exercise  may  be  taken  without 
difficulty,  normal  blood-pressure  is  corroborative  testimony  that 
the  symptoms  are  not  associated  with  cardio-vascular  disease, 
and  the  prognosis  may  be  good.  Great  care  must  be  used  in 
deciding  on  these  cases,  nevertheless. 

The  case  recorded  on  page  176  illustrates  tlie  ordinary  anginoid  type 
with  hypertension.  The  following  history  is  instructive  as  showing  the 
sudden  development  of  intense  angina  pectoris  after  rej^eated  slighter 
attacks.  A  gentleman,  sixty-one,  who  had  been  a  very  hard  worker,  liberal 
in  his  diet  and  use  of  stimulants  and  tobacco,  had  noticed  for  a  year  that 
fast  walking  gave  him  distress  across  the  upper  sternum,  and  slight  dys- 
pnoea. As  the  distress  would  pass  off  when  he  slacked  his  sjieed,  he  paid 
no  attention  to  it,  beyond  reducing  his  ordinary  gait.  After  some  months 
the  attacks  became  more  frequent  and  severe,  and  followed  slighter  exer- 
tion. In  March  he  consulted  Dr.  Osier,  who  gave  him  amyl  nitrite  for 
emergency  use,  and  cautioned  him  to  avoid  all  strain.  Shortly  after  this, 
while  on  a  railway  train,  he  was  seized  with  excruciating  pain  in  the  chest, 
running  down  both  arms  to  the  elbow.  He  broke  off  his  journey,  and  for 
three  weeks  was  unable  to  lie  down  without  bringing  on  intense  pain.  He 
had  slight  oedema  of  the  legs  at  that  time.  With  the  continued  use  of 
nitroglycerin,  y^o  S^'-  ^  '^^7'  ^^^  improved,  and  four  mouths  later  could 
walk  half  a  mile  on  the  level.  He  said  that,  when  the  pain  would  come  on, 
he  felt  as  though  he  would  stop  breathing  and  drop.  Physical  examina- 
tion, four  months  after  the  intense  seizure,  showed  merely  faint  heart 
sounds  with  a  very  slight  basic  systolic  murmur.  As  he  weighed  two 
hundred  and  forty  pounds,  no  satisfactory  percussion  was  possible.  Heart 
action  was  slow  and  regular.  Systolic  pressure  was  only  IG.'j  mm.  (R.  E. 
5  cm.),  distinctly  low  for  the  size  of  arm.  The  urine  showed  a  few  hyaline 
casts  only.     Two  years  later  he  was  living  and  attending  to  business. 

Another  patient  shows  the  possibility  of  a  relatively  good  prognosis. 
He  is  sixty  years  old,  and  for  nine  years  has  suffered  some  jirecordial  dis- 
tress on  exertion.  For  four  years  there  has  been  distinct  anginal  pain  at 
times,  always  after  effort.  Two  years  ago  he  was  obliged  to  climb  a  short 
but  steep  incline  in  winter,  and  had  intense  angina  pectoris;  but  subse- 
quently he  has  never  had  a  severe  attack.  Now,  walking  against  the  wind, 
or  a  fit  of  anger,  precipitates  an  anginoid  seizure,  but  nothing  like  his  past 
ones.  He  has  a  simple  hypertroi^hy  of  the  heart,  without  murmurs  or 
nephritis,  a  typical  angio-sclerosis,  or  eardio-sclerosis,  as  Huchard  would 
put  it.  His  systolic  pressure  is  215  mm.,  diastolic  145  mm.  (5  cm.).  He 
improved  very  much  on  continued  small  doses  of  iodide,  and  nitroglycerin 
relieves  his  attacks  inomptly. 

b.  Cardiac  Asthma  and  Cheyne-Stokes  Breathing. — The  sponta- 
neous attacks  of  dyspncx-a  so  i'rutpicnt  in  cardiac  and  nephritic 


DISEASES  OF  HEART,  ARTERIES  AN  J)  KIDNEYS  205 

cases  are  very  commonly  associated  with  hypertension.  In 
their  most  severe  form  actual  oedema  of  the  lungs  occurs,  and 
the  danger  to  life  is  extreme,  as  in  the  cases  previously  men- 
tioned. Fig.  49  shows  an  observation  I  was  able  to  make 
during  an  intense  seizure.  Since  Cohnheim  and  Welch  (see 
page  150)  showed  that  a  paralysis  of  the  left  ventricle,  with  the 
right  still  beating,  was  the  mechanical  cause  of  pulmonary 
oedema,  where  hypertension  exists  it  demands  immediate  relief, 
to  lessen  the  work  of  the  weakened  left  heart,  before  cardiac 
stimulants  can  be  safely  used.  The  sphygmomanometer  in 
this  condition  gives  important  therapeutic  indications.  As  the 
danger  is  urgent,  the  rapidly  acting  amyl  nitrite  or  nitroglyc- 
erin are  the  best  drugs,  though  even  these  may  be  disappointing. 
The  severer  forms  of  dyspnoea  may  also  be  a  cause  of  hyper- 
tension, as  V.  Basch  and  Hensen  have  shown.  The  effect  is 
of  course  through  the  vaso-constrictor  centres,  as  we  have  seen 
in  experimental  asphyxia  (see  page  37). 

In  JJheyne-Stokes  breathing,  variation  in  the  size  of  the 
pulse  with  the  periodic  changes  in  respiration  is  usually  ob- 
served. Gumprecht  noted  it,  and  Norris  found  the  pressure 
as  much  as  25  mm.  lower  in  the  period  of  apnoea.  The  phe- 
nomenon is  probably  caused  by  variation  in  the  tonus  of  the 
vaso-motor  centre,  synchronous  with  that  of  the  respiratory 
centre,  due  to  partial  anaemia  of  the  medulla  (see  page  140). 

c.  The  Arrhythmias.— Irregularities  of  the  pulse  affect  both 
time  and  volume  rhythm.  Only  the  latter  lend  themselves  to 
sphygmomanometric  study.  When  present  they  make  observa- 
tions difficult,  especially  for  diastolic  pressure.  I  am  accus- 
tomed to  note  separately  the  systolic  pressure  of  the  largest 
and  of  the  smallest  pulse-waves,  and  the  approximate  diastolic 
pressure.  In  this  way  a  permanent  record  of  the  absolute 
amount  of  volume  irregularity  is  obtained.  I  have  seen  as 
much  as  40  to  60  mm.  difference  in  systolic  pressure  within  a 
few  seconds,  in  cases  of  mitral  stenosis  or  myocardial  disease. 
The  smaller  variations  of  10  to  20  mm.  are  usually  overlooked 
without  the  sphygmomanometer.  This  brings  them  into  relief, 
because,  while  maintaining  the  pressure  at  just  sufficient  to 
obliterate  the  average  pulses,  occasional  fuller  ones  will  come 
through  in  a  striking  way.  In  true  bradycardia,  or  the  pulsus 
alternans,  the  difference  between  systolic  and  diastolic  pressure 


Mq^c/.  2.LI 

l^ve    Tnivtut'e   inter va.(.S. 

Blood  Pressure. 
Pulse  Rate. 

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Fig.  49. 


Fig.  49. — CEdema  of  the  lungs.    (Author's  sphygm.  12  cm.) 

Chart  from  W.  G'B.,  aged  twenty-eight,  male,  City  Hospital.  Admitted  March  19th, 
with  slight  gouty  attack  and  chronic  nephritis.     Pressure  on  admission  120  mm. 

Acute  general  oedema  of  the  lungs  began  just  before  Y.50  p.  m.,  and  ushered  in  a  rapidly 
fatal  pneumonia. 

Note  the  slight  and  transient  effect  of  the  vaso-dilators. 


208     BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

is  greatly  increased,  as  I  have  personally  observed.  In  this 
condition,  as  in  aortic  insufficiency,  the  measurement  of  sys- 
tolic pressure  alone  shows  a  false  hypertension. 

The  paradoxical  pulse,  and  slighter  grades  of  inspiratory  fall, 
in  systolic  pressure,  have  been  especially  studied  by  Hensen. 
He  considers  them  alike  signs  of  circulatory  weakness.  The 
lesser  grades  can  only  be  detected  with  the  sphygmomanometer, 
and  are  found  in  uncompensated  heart  lesions,  pleural  effusion, 
and  even  at  times  during  febrile  disease.  As  terminal  phe- 
nomena they  are  common.  The  marked  paradoxical  pulse  of 
Riegel,  in  laryngeal  stenosis,  pericardial  adhesions  or  effusions, 
etc.,  is  palpable  as  well  as  measurable.  Hensen  saw  a  differ- 
ence of  40  mm.  between  inspiratory  and  expiratory  pressure  in 
laryngeal  diphtheria.  In  my  experience  it  has  been  most  fre- 
(juent  with  asthma  or  marked  emphysema.  Complete  absence 
of  pulse  during  inspiration  I  saw  recently  in  a  man  with  peri- 
cardial and  loft  pleural  effusion. 

H.  Effect  of  Exertion  on  Blood-Pressure  in  Cardio-vascular  Dis- 
eases.— Our  estimate  of  the  functional  ability  of  a  heart  is  usu- 
ally more  or  less  roughly  made  from  the  symptoms  developed 
under  the  exertion  of  daily  hfe.  The  study  of  the  blood-pres- 
sure and  pulse-rate,  during  the  performance  of  a  measured 
amount  of  work,  ought  to  render  our  judgments  more  accurate. 
This  has  been  done,  at  the  suggestion  of  Dehio,  by  Moritz  for 
cardiac  patients,  in  the  same  way  as  by  Masing  for  the  aged. 
Dehio's  apparatus  is  shown  in  Fig.  50,  and  can  be  easily  ar- 
ranged in  any  hospital.  The  work  is  performed  by  one  leg,  in 
time  with  a  metronome,  and  pressure  and  pulse  measurements 
from  the  arm  are  not  interfered  with.  In  Dehio's  investiga- 
tions a  weight  of  4,090  grams,  about  eight  pounds,  was  lifted 
40  cm.  =  lof  inches,  fifty  times  a  minute,  giving  an  actual  per- 
formance of  81..S  kilogrammetres  a  minute.  A  weight  of  five 
pounds  lifted  a  foot  would  seem  to  mo  a  good  average,  and  I 
am  arranging  such  an  apparatus  at  the  City  Hospital.  The 
work  from  this  will  be  five  foot-pounds  at  each  stroke.  Pres- 
sure determinations  should  be  at  three-  to  five-minute  intervals. 
Moritz's  results,  in  cases  of  cardiac  weakness,  are  similar  to 
Masing's  for  the  aged  (whom  Dehio  believes  have  "myofibrosis 
cordis"),  and  Fig.  40  illustrates  the  typical  curve,  save  for  the 
slow  senile  pulse.     The  initial  rise  in  pressure  was  more  pro- 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  209 


nounced  than  in  the  normal  man,  but  was  not  maintained,  a 
fall  occurring  during  the  exertion.  In  the  normal  persons  a 
steady  level  of  pressure  continues  throughout,  unless  the  work 
be  very  excessive.  With  the  falhng  pressure,  dyspncea  and 
distress  developed.  Butterman  made 
similar  observations  with  the  tonome- 
ter and  work  in  a  Gartner  ergostat. 
Compensated  mitral  lesions,  nervous 
hearts,  etc.,  reacted  with  a  normal 
rise,  averaging  13  mm.  They  had  no 
great  dyspnoea.  Other  patients  with 
myocardial  disease,  who  had  much 
distress  on  exertion,  showed  a  diminu- 
tion in  tension  of  3  to  14  mm.     Schott 


G 


C 


b"iG.  50. — Dehio's  apparatus.     (From  Dt-liio.) 

For  porforiiiin.fr  a  measured  amount  of  work  with  the  leps. 

The  cord,  which  holds  the  weight  (D),  passes  over  the  pulleys  (A  A),  and  under  the 
pulley  (B),  fastened  to  tlie  upright  (C),  and  liooks  into  the  foot-bandage  (E).  The  height 
of  the  stop  (G)  fixes  the  distance  the  weight  travels. 

found  a  marked  faU  in  pressure  when  lasting  dyspnoea  ap- 
peared. This  simple  method  of  functional  heart  diagnosis 
deserves  a  careful  trial  by  those  who  have  to  advise  cardiac 
patients  as  to  the  ordering  of  their  daily  life.  Exercise,  if  not 
15 


210    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

harmful  to  their  hearts,  is  so  advantageous  for  their  general 
health  and  happiness,  that  a  more  accurate  method  of  judging 
its  effects  seems  a  practical  desideratum. 

L  Therapeutics. — The  treatment  of  diseases  of  the  cardio- 
vascular system  has,  as  its  primary  object,  the  improvement 
of  the  capillary  circulation,  so  that  it  may  be  adequate  to  the 
demands  of  the  tissues  for  oxygen  and  nutriment,  and  for  the 
removal  of  waste  products.  The  ability  of  the  heart  to  main- 
tain an  adequate  circulation  may  be  complete  during  repose, 
but  most  deficient  during  forced  exertion.  The  regulation  of 
the  patient's  entire  life  becomes,  then,  the  starting-point  of 
treatment,  and  should  include  the  avoidance  of  all  those  forms 
of  exertion  and  excitement  which  cause  considerable  increase 
of  arterial  pressure,  especially  of  a  sudden  nature.  Of  the  pos- 
sibihty  of  following  the  results  of  this  general  hygienic  treat- 
ment with  the  sphygmomanometer  I  am  unwillmg  to  speak 
with  conviction.  The  effects  would  only  be  evident  after  a 
considerable  lapse  of  time,  and  other  causes  for  blood-pressure 
variation  would  compHcate  the  situation.  The  attempt,  how- 
ever, should  certamh'  be  made. 

Of  the  various  dietetic  and  phj'sical  measures,  massage, 
baths,  etc.,  I  do  not  feel  competent  to  speak.  The  good  which 
they  do  must  also  be  a  rather  permanent  one,  of  a  nature  hard 
to  foUow  b}'  the  blood-pressure.  Schott  has  \ATitten  on  the 
effect  of  the  Nauheim  baths  on  blood-pressure,  but  to  correlate 
his  findings  and  the  benefit  received  bj^  the  patient  is  another 
matter,  v.  Basch  and  Huchard  lay  great  stress  on  these  meth- 
ods of  combatting  hypertension,  and  I  think  rightly ;  but  it  must 
be  more  with  a  view  to  limiting  a  process  already  initiated,  than 
of  causing  its  disappearance. 

As  we  have  already  seen,  in  discussing  the  value  of  the 
blood-pressure  as  a  guide  to  the  functional  ability  of  the  heart 
and  circulation,  it  gives  us  scarcely  any  clue  to  the  work  per- 
formed by  the  heart.  Hence  we  find,  in  the  records  of  blood- 
pressure  during  treatment  of  uncompensated  heart-lesions, 
everj^  variation.  Christeller,  Frenkel,  Heike,  Hensen,  Gross, 
and  Potain,  all  fail  to  find  an}^  relation  between  the  arterial 
tension  and  the  circulatory  improvement  from  digitalis.  This 
point  is  important,  for  it  makes  it  clear  that  the  effect  of  many 
circulatory  drugs,  of  undoubted  stimulant  properties,  will  not 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  211 


be  visible  on  the  pressure  chart;  because  altered  blood-distri- 
bution, and  not  increased  blood-pressure,  is  their  best  result. 
In  hypotensive  states,  their  effect  on  pressure  is  more  evident. 
The  main  value  of  sphygmomanometric  observations,  during 
the  treatment  of  cardiac  cases,  is  in  the  avoidance  of  undue 
hypertension. 

The  effect  of  the  vaso-dilators,  on  the  other  hand,  may  and 
should  be  studied.  Nitroglycerin,  amyl  nitrite,  sodium  nitrite, 
and  even  spiritus  etheris  nitrosi,  produce  an    evident  fall  in 


Blood  Pressure. 

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(Author's  sphygm.  12  cm.) 

Chart  from  same  case  of  general  arterio-sclerosis  as  Fig.  45. 

(1)  Nitroglycerin,  gr.  Vioo,  dissolved  in  mouth. 

(2)  Caffein-sodium  salicylate,  gr.  ij,  by  mouth. 

pressure.  The  first  two  act  with  surprising  rapidity  and  vigor, 
but  their  effect  is  very  transient  (see  Figs.  42,  44,  49,  51  and 
52).  Carter  found  marked  and  more  permanent  effects  from 
sodium  nitrite,  the  pressure  remaining  low  for  an  hour  or  so. 
Without  blood-pressure  measurements,  clinicians  forget  the 
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Fig,  52. — Fall  in  blood-pressure  produced  by  nitroglycerin,  gr.  ^/5o. 
(Author's  sphygm.  12  cm.) 

Chart  from  same  case  of  chronic  interstitial  nephritis  as  Fig.  42. 

(1),  (2),  and  (3).  Nitroglycerin,  gr.  1/50,  given  by  hypodermic,  for  relief  of  severe 
nose-bleed.  When  the  pressure  reached  95  mm.  patient  was  light-headed  and  sweating, 
and  nose-bleed  had  ceased.     Immediately  after,  she  went  to  sleep. 

(Observation  by  Dr,  Higgins.) 


214    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

as  a  vaso-dilator,  is  the  subject  of  great  dispute.  It  certainly 
has  not  the  immediate  measurable  effect  of  the  nitrites,  and 
cannot  be  classed  as  an  active  vaso-dilator.  Nevertheless,  I 
have  seen  relief  of  anginal  pain  on  exertion  so  frequently  fol- 
low its  continued  use  in  small  doses,  with  an  apparently  lower 
level  of  tension,  that  I  am  convinced  that  it  has  an  effect  com- 
parable with  the  hygienic  and  dietetic  measures,  when  long 
periods  are  considered.  Some  of  the  cases  cited  earlier  show 
this.  Huchard  vaunts  its  virtues  in  cardio-sclerosis ;  v.  Basch 
thinks  it  of  small  value.  One  must  always  remember,  also, 
that  essential  hypertension  may  be  a  compensatory  phenome- 
non, and,  if  the  anatomical  or  functional  cause  of  increased 
peripheral  resistance  is  permanent,  it  may  be  most  unwise  to 
attempt  to  lower  blood-pressure.  In  kidney  diseases,  for  in- 
stance, lowered  pressure  may  be  the  cause  of  diminished  blood- 
flow  through  the  kidney  and  decreased  urinary  excretion,  an 
undesirable  result. 

The  most  important  therapeutic  indications  of  the  sphyg- 
momanometer are  in  conditions  of  dangerous  hypertension, 
such  as  uraemia,  and  in  paroxysms  of  angina  pectoris.  Here 
rapid  vaso-dilators  are  called  for.  In  uraemia,  the  other  meth- 
ods for  reducing  tension  come  into  play.  Venesection  is  one  of 
the  best,  and  Butterman,  Carter,  and  Hayaski,  all  report 
marked  reduction  in  pressure  from  it.  Sweating  has  a  similar 
effect,  and  is  commonly  attended  by  a  fall  in  pressure,  so  that 
the  double  purpose  of  reducing  pressure  and  eliminating  poi- 
sons is  achieved.  Purgation  may  also  assist.  In  the  light  of 
recent  investigation,  the  depleting  treatment  of  hypertension 
dependent  on  acute  cerebral  compression  must  remain  ques- 
tionable. Its  effects  should  certainly  be  controlled  by  blood- 
pressure  determinations. 

LITERATURE 

Ascoli,  G.     Vorlcsungen  iiber  Uriimie.     Jena,  1902,  pp.  113-117. 

V.  Basch,  S.     Die   Herzkrankheiten  bei  Arterioscleiose.     Berlin,  1901. 

Der  Sphygmomanometer  und  seine  Verwerthuug  in  der  Praxis.    Berl. 

klin.  Wochenschr.,  1887,  vol.  xxiv,  p.  179. 
Butterman.     Einige  Beobachtungen  iiber  das  Vcrhalten  des  Blutdrucks 

bei  Kranken.     Deutsch.  Arch.  f.  klin.  Med.,  1902,  vol.  Ixxiv,  p.  1. 
Carter,  H.  W.     Clinical  Observations  on  Blood-pressure.     Am.  Jour,  of 

the  Med.  Sci. ,  1901,  vol.  cxxii,  p.  854. 


DISEASES  OF  HEART,  ARTERIES  AND  KIDNEYS  215 

Christeller.     Ueber  Blutdiuckraessungen   an   Menschen   uuter  patholo- 

gisclien  Verbiiltnisseu.     Zeitschr.  f.  klin.  Med.,  1881,  vol.  iii,  p.  33. 
Cook,  H.  W.,  and  Briggs,  J.  B.     Clinical  Observations  on  Blood-pressure. 

Johns  Hopkins  Hosp.  Eep.,  1903,  vol.  xi,  p.  451. 
Cushing,  H.  W.     The  Blood-pressure  Eeaction  of  Acute  Cerebral  Com- 
pression, Illustrated  by  Cases  of  Intracerebral  HsBmorrLage.     Am. 

Jour,  of  the  Med.  Sci.,  1903,  vol.  cxxv,  p.  1017. 
Dehio,  K.     Ueber  das  Altern  des  Herzens.    St.  Petersburg  med.  Wochen- 

schr.,  1901,  vol.  xviii,  i).  79. 
Edel,  P.     Ueber  die  Abhiingigkeit  der   "cyklischen"  Albuminuric  von 

der  Cirkulation.     Deutsch.   med.  Wochenschr. ,   1902,  vol.  xxix,  pp. 

639  and  663. 
Ekgren,  E.     Ein  eigenartiger  Blutdruckbefund  bei  einem  Falle  von  Me- 

diastinaltumor.     Fortsch.  d.  Med.,  1902,  vol.  xx,  p.  4. 
Erlanger,  J.,  and  Hooker,  D.  E.     The  Eelation  of  Blood-pressure  and 

Pulse-pressure  to  the  Secretion  of  Urine  and  to  the  Secretion  of  Al- 
bumin in  a  case  of  So-called  Physiological  Albuminuria.     Am.  Jour. 

of  Physiol.,  1904,  vol.  x.  Proceed,  of  Am.  Physiol.  Soc,  p.  xvi. 
Forlanini.     Eeudiconti  del  E.  1st.     Lombardo,  1901.     Quoted  by  Ascoli. 
Frenkel,  S.     Klinische  Untersuchungen  iiber  die  Wirkung  von  Coflfein, 

u.  s.  w.     Deutsch.  Arch.  f.  klin.  Med.,  1890,  vol.  xlvi,  p.  542. 
Giglioli,  G.  T.     Alcune  critiche  e  alcune  richerche  di  sfigmomanometria 

clinica.     Eiv.  crit.  di  clin.  Med.,  1900,  vol.  i,  pp.  625  and  641. 
Goldwater,  S.  S.     Notes  on  Blood-j)ressure  in  Man.     Med.  News,  New 

York,  1903,  vol.  Ixxxii,  p.  926. 
Gross,  A.    Zur  Kenntniss  der  pathologischen  Blutdruckanderungen  nach 

Beobachtungen  von  well.  Dr.  H.  Hensen.     Deutsch.  Arch.  f.  klin. 

Med.,  1902,  vol.  Ixxiv,  p.  296. 
Gumprecht.     Experimentelle  und  klinische  Priifung  des  Eiva-Rocci'schen 

Sphygmomanometers.     Zeitschr.  f.  klin.  Med.,  1900,  vol.  xxxix,  p.  377. 
Hayaski,  T.     Vergleichende     Blutdruckmessungen    an    Gesunden    und 

Kranken   mit  den   Apparaten  von   Gartner,  Eiva-Eocci    und    Frey. 

Inaug.  Dissert.,  Erlangen,  1901. 
Heike,  Wilhelm.     Blutdruckmessungen  nach  Verabreichung  von   Digi- 
talis, ausgefuhrt  mittels  des  Eiva-Eocci'schen  Sphygmomanometers. 

Inaug.  Dissert.,  Halle,  1901,  Aug. 
Hensen,  H.     Beitrage  zur  Physiologic  und  Pathologie  des  Blutdrucks. 

Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol.  Ixvii,  p.  438. 
Hochhaus,    H.     Ueber    functionelle    Herzkrankheiten.     Deutsch.    med. 

Wochenschr.,  1900,  vol.  xxvi,  p.  701. 
Huchard,  H.     La  medication  hypotensive.     Paris,  1903. 
Jackson,  J.  M.     A  Few  Eemarks  on  Blood-pressure.     Boston  Med.  and 

Surg.  Jour.,  1903,  vol.  cxlviii,  p.  223. 
Jarotzny,   A.     Zur  Methodik   der   klinischen   Blutdruckmessung.     Cen- 

tralbl.  f.  in.  Med.,  1901,  vol.  xxii,  p.  599. 


216    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

Jourdin,  Ch.,  et  Fischer,  G.     De  I'iiiiportance  pionostique  et  thC-rapeu- 

tique  de  la  pressiou  aitcrielle      Rev.  de  Med.,  1902,  vol.  xxii,  p.  915. 
Kaufmann,  J.,  und  de  Bary,  W.    Ueber  die  Einwirkungeu  Priessuitz'scher 

Einwickelungen  auf  den  Blutdiuck  bei  crouposer  Pueuinonie  und 

diflfuser  Nephritis.     Berl.  klin.  Wochenschr.,  1888,  vol.  xxv,  p.  557. 
Laqueur,  A.     Zur  Kenntniss  uriimischer  Zustande.     Deutscli.  med.  Wo- 
chenschr., 1901,  vol.  xxvii,  p.  744. 
Masing,  Ernst.     Ueber  das  Verhalten  des  Blutdrucks  des  juugen  und  des 

bejahrten  Menschen  bei  Muskelarbeit.     Deutsch.  Arch.  f.  klin.  Med., 

1902,  vol.  Ixxiv,  p.  255. 
Moritz,  O.     Der  Blutdruck  bei  Korperarbeit  gesunder  und  herzkranker 

Individuen.     Deutsch.  Arch.  f.  klin.  Med.,  1903,  vol.  1  xxvii,  p.  339. 
Norris,  G.  W.     A  Contribution  to  the  Study  of  the  Human  Blood-pressure 

in  some  Pathological  Conditions.     Am.  Jour,  of  the  Med.  Sci.,  1903, 

vol.  cxxv,  p.  888. 
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p.  417. 
Ueber  Gefasskrisen  und  deren  Beziehungen  zu  den  Magen  und  Bauch- 

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Overstraining  of  the  Heart.     New  York  Med.  Jour.,  1902,  vol.  Ixxv, 

p.  705. 
Tonometric  Examinations  in  Chronic  Diseases  of  the  Heart.     Med. 

Record,  New  York,  1901,  vol.  lix,  p.  1028. 
SChiile.     Ueber  Blutdruckmessungen  mit  dem  Tonometer  von  Gartner. 

Berl.  klin.  Wochenschr.,  1900,  vol.  xxxvii,  p.  726. 
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in.  Med.,  1902,  vol.  xxiii,  p.  849. 
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xvn\  p.  279. 


2.    ACUTE   INFECTIOUS   DISEASES 

In  acute  infections,  the  main  ground  for  the  advocacy  of 
routine  blood-pressure  estimations  must  be  sought  in  the  ex- 
perimental evidence  of  the  vaso-motor  origin  of  collapse.  Any 
means  which  will  help  to  foretell  its  dread  ai)pearance,  if  in  but 
a  fraction  of  the  cases  we  meet,  is  well  worth  while.  The 
sphygmomanometer  would  seem  to  offer  this  prospect,  but  its 


ACUTE   INFECTIOUS   DISEASES  217 

absolute  value  has  not  yet  been  determined.  For  diagnosis  it 
naturally  means  little  or  nothing,  but  for  prognosis,  and  as  a 
guide  to  treatment,  there  is  good  ground  for  believing  that  it 
will  come  more  and  more  to  the  front. 

Single  observations  are  meaningless  in  these  conditions ; 
only  careful  records,  as  of  the  temperature  and  pulse,  can  give 
the  desired  information.  Any  such  grouping  of  diseases  on 
the  basis  of  their  typical  blood-pressure,  as  Potain  carries  it 
out,  is  worthless  for  the  acute  diseases,  though  we  may  dis- 
tinguish a  difference  in  the  regularity  with  which  they  affect 
pressure.  The  greatest  hindrance  to  determining  the  real  use 
of  the  sphygmomanometer  in  febrile  conditions  to-day  is  the 
lack  of  sufficiently  trustworthy  facts.  The  bulk  of  the  studies 
have  been  made  with  the  Potain  or  v,  Basch  instruments, 
many  even  with  the  impossible  one  of  Verdin. 

A.  Typhoid  Fever. — In  typhoid  fever,  more  than  in  any  other 
acute  disease,  the  sphygmomanometer  has  proved  its  worth. 
As  a  guide  to  treatment,  as  a  help  in  the  diagnosis  of  perfora- 
tion and  its  differentiation  from  concealed  hsemorrhage,  and  be- 
cause it  affords  an  additional  prognostic  standpoint,  it  should 
be  generally  used.  We  owe  especial  gratitude  to  Crile,  and  to 
Cook  and  Briggs,  for  our  knowledge,  though  some  of  their  re- 
sults may  fail  of  universal  confirmation.  To  be  of  any  service, 
blood-pressure  must  be  recorded  at  the  same  intervals  as  tem- 
perature and  pulse-rate,  best  on  charts.  Those  who,  like 
Norris,  find  no  prognostic  value,  made  observations  once  in  a 
few  days  only.  Used  in  such  a  way  the  thermometer  would 
be  equally  valueless.  Typhoid  fever  is  almost  invariably  hypo- 
tensive, as  Potain  in  116  cases,  Crile  in  115,  and  Alezais  and 
Francois  in  150,  proved  conclusively.  Unfortunately  the  latter 
observers  used  a  very  defective  method  (Yerdin's  sph3^gmo- 
meter,  see  page  45),  and  Potain's  own  is  not  free  from  suspi- 
cion. The  fall  in  pressure  begins  in  the  first  or  second  week 
and  goes  hand  in  hand  with  the  development  of  the  toxtemia. 
The  absolute  pressure  means  little  of  itself.  The  important 
matter  is  its  general  course.  Gumprecht  calls  attention  to  the 
marked  variations  which  occur,  as  they  do  in  a  normal  man, 
throughout  the  day.  Alezais  and  Francois's  statements  on 
this  point  cannot  be  accepted  on  account  of  the  instrument  used. 
I  think,   however,   that    fluctuations  of  short  duration,  up  to 


o  ©  p  oO 


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o  3     '3 


ACUTE  INFECTIOUS   DISEASES 


219 


25  mm.,  are  of  no  serious  import.     Crile's  figures  are  of  partic- 
ular interest. 

In  115  cases  the  highest  pressure  =138  mm,  (R.  R.  5  cm.). 
"    lowest         "  =    74  mm. 

"    mean  "  =  104  mm. 

The  mean  pressure  of  all  cases,  by  weeks  of  the  disease,  was 
as  follows:  first  week,  115  mm.;  second,  lOG  mm.;  third,  102 
mm. ;  fourth,  90  mm. ;  fifth,  98  mm.  Nothing  could  better 
illustrate  the  gradual  development  of  hypotension. 

Hensen,  Neisser,  and  Hayaski  also  report  on  smaller  groups 
of  cases. 

a.  Haemorrliage  and  Collapse. — A  slowly  progressive  fall  in 

pressure  is  evidence  of  increasing  weakness  of  the  vaso-motor 

centres,  and  of  the  danger  of  impending  collapse.     It  calls, 

fffff^^^f..  .... 


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150 
140 
130 
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100 
90 
80 
70 
60 
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40 
30 
20 

to 


Fig.  54. — Typhoid  fever — intestinal  haemorrhage.     (Cook's  sphygm.  5  cm.) 


Blood-pressuro  level  broken  by  a  sharp  fall  with  the  fir.st  hsemorrhagc,  with  no  pre- 
cedent rise  in  tension— distinction  from  intestinal  perforation.  The  fall  continues  with 
a  second  haemorrhage.  mi        -i,     • 

Gradual  return  of  blood-pressure  after  the  cessation  of  hremorrhage,  The  physio- 
logical return  aided,  though  the  curve  is  not  materially  altered,  by  a  small  dose  fgr.Vso) 
of"strychnin  and  a  small  saline  infusion.     (From  Cook  and  Briggs,  Chart  ISio.  .vXIII.) 


220     BLOOD-PRESSURE   IN    INTERNAL   DISEASES 


therefore,  for  stimulant  medication.  A  rapid  fall  suggests 
haemorrhage.  Neither  Cook  and  Briggs,  nor  Alezais  and 
Francois,  failed  to  observe  this  in  any  case.  All  other  com- 
plications are  attended  by  some  fall  in  pressure,  except  pneu- 
monia and  perforative  peritonitis. 

b.  Perforation. — In  the  latter  condition  Crile,  and  Briggs, 
have  both  found  a  sharp  rise  marking  its  onset.     The  number 


210 
200 


143 
130 
120 

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Flo.  55. — Typhoid  kkveh — intestinal  peufokation.     (Cook's  spliyjiin.  5  cm.) 

Level  curve  of  blood-pressure  for  days  before  the  onset  of  the  conipliciition. 

Sharp  rise,  iiriioutUiiiK  to  30  mm.  Ug.  in  blood-pressure,  over  four  hours  before  the 
onset  of  symptoms  pointing'  to  the  al)domen,  and  at  a  time  when  the  abdomen  was  soft 
and  tcniler,  and  not  distended. 

Tendency  of  the  blood-pressure  to  return  to  a  low  level  as  the  toxromia  deepened. 
Slifrht  post'Operative  depression.    (From  Cook  and  Brigf,'s,  Chart  No.  XXII.) 

of  cases  does  not  suffice  for  absolute  statements,  but  the  similar 
heightening  of  tension  in  peritonitis  from  other  causes,  which 
Crile  found  invariable  in  20  surgical  patients,  makes  it  probable 


ACUTE   INFECTIOUS   DISEASES  221 

that  a  relative  hypertension  will  be  the  usual  result  of  perfora- 
tion. In  one  of  Crile's  patients  the  pressure  rose  from  IIG  mm. 
to  165  mm,  in  two  hours,  and,  in  another,  from  116  mm.  to  190 
mm.  in  four  hours.  In  two  others,  without  previous  record, 
165  mm.  and  208  mm.  were  the  figures,  a  striking  contrast  to 
his  highest  reading  of  138  mm.  in  uncomplicated  typhoid.  In 
a  fifth  case,  the  elevation  was  only  from  84  mm.  to  110  mm. 

Since  the  differential  diagnosis  of  perforation  is  always  dif- 
ficult, and  the  other  accidents  which  come  in  question,  con- 
cealed haemorrhage  and  acute  collapse,  produce  a  fall,  this 
sharp  elevation  of  pressure  may  often  be  of  inestimable  value. 

From  the  other  aspect  of  the  problem  Briggs  reports  one 
case,  with  chnical  symptoms  pointing  to  perforation,  but  no 
pressure  rise.  Operation  was  undertaken,  but  the  perforation 
was  not  present.  Full  reports  of  all  such  cases  should  be  made, 
that  the  value  of  the  blood-pressure  chart,  both  as  positive  and 
negative  evidence  of  perforation,  may  be  established.  A  later 
fall  of  pressure,  as  a  terminal  event  in  the  subsequent  perito- 
nitis, must  be  distinguished  from  the  initial  hypertension,  which 
can  only  be  detected  in  continuous  records.  It  is  of  no  use 
to  apply  the  sphygmomanometer  after  abdominal  symptoms 
occur,  without  knowledge  of  the  previous  trend  of  pressure. 

c.  Therapeutics. — The  bath  treatment  of  typhoid  fever  seems 
to  have  as  distinct  an  effect  on  the  blood-pressure  curve,  as  on 
temperature  and  pulse.  When  it  acts  favorably,  a  considerable 
rise  is  produced,  as  shown  in  Fig.  53.  Mercandino  found  a 
more  uniform  rise  from  it  than  from  any  stimulant  drug.  I 
cannot  but  feel  that  this  hypertensive  effect  is  evidence  of  an 
action  on  the  vaso-motor  system,  which  is  of  more  importance 
than  the  reduction  of  temperature,  and  that  the  sphygmoma- 
nometer may  give  indications  for  the  employment  or  abandon- 
ment of  this  method  of  treatment  in  particular  cases.  Cook 
and  Briggs  have  found  strychnin  and  digitalin  the  most  useful 
drugs  for  combatting  collapse  and  hypotension.  Where  urgent 
need  exists,  they  give  as  much  as  one-tenth  of  a  grain  of  either. 
Digitalin  acted  the  more  quickly.  A  combination  of  both 
seemed  most  generally  useful.  Mercandino,  on  the  other  hand, 
and  Schlile,  as  is  the  case  with  continental  practitioners  in  gen- 
eral, prefer  camphor  and  caffein  to  all  others.  This  accords 
with  Passler's  experimental  findings  in  collapse,  strj^chnin  hav- 


222    BLOOD-PRESSURE  IN  INTERNAL  DISEASES 

ing  acted  on  blood-pressure  only  in  toxic  dose,  digitalis  tempo- 
rarily through  strengthening  the  heart,  and  caff  ein  and  camphor 
causing  a  considerable  rise.     It  is  to  be  hoped  that  chnicians 


200 
190 
ISO 
170 
tM 
ISO 
140 
130 
120 

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too 

90 
80 


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130 
120 

no 

100 
90 

to 

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50 
40 
30 
20 

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Fig.  56. — Typhoid  fever  with  tox.emio  features  and  hypotension. 
(Cook's  sphygm.  5  cm.) 

Rise  in  blood-pressure  following  each  of  several  doses  of  diiritaliii  hypodermically. 

Alcohol  by  iiioutli  and  strychnin  hypodermically,  without  any  beneficial  eflfeet  on  tlie 
blood-pressure,  even  durin};  a  period  of  acute  depression  (threatened  collapse).  (From 
Cook  and  Brings,  Chart  No.  XXV.) 

generally  will  study  the  action  of  drugs  on  blood-pressure  in 
acute  disease.  The  subject,  hke  all  clinical  therapeutics,  is 
involved  in  all  manner  of  contradictions  to-day.  It  is  possible 
that  some  remedial  agents  are  of  use  in  disease,  which,  neither 
in  normal  men,  nor  in  animals,  can  be  proved  to  have  defi- 
nite physiological  effects.  The  stimulants,  however,  cannot 
fall  into  such  a  category,  and  we  should  not  employ  as 
cardio-vascular  stimulants,  drugs,  whose  effects  on  blood- 
pressure  cannot  be  demonstrated.  Empiricism  is  still  essential 
to  the  practice  of  medicine,  because  the  scientific  study  of 
disease  has  covered  but  a  small  portion  of  its  field;  but  let  us 
be  honest   empirics,    when   we    must,   and   stop   hiding   our 


ACUTE  INFECTIOUS  DISEASES 


223 


ignorance  behind  the  mask  of  scientific  terminology.  Least  of 
all  so-called  stimulants  does  alcohol  deserve  the  name.  As  in 
animals  and  normal  men  it  is  without  influence  on  the  blood- 
pressure  or  the  force  of  the  heart,  so  in  disease  the  same  holds 
true.  Cook  and  Briggs,  Cabot,  Mercandino,  Schiile,  and  Swien- 
tochowski,  have  all  corroborated  this  by  sphygmomanometric 
studies.  This  does  not  negative  any  value  of  alcohol  as  a  food,  or 
for  effect  on  the  nervous  system  or  blood-distribution,  in  fevers  ; 
but  it  does  teach  us  not  to  rely  upon  it  as  a  means  of  fighting 


riQf>QU'/ 

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Fig.  57. — Absence  of  ant  rise  in  blood-peessube  after  the  subcutaneous 
INJECTION  OF  ADRENALIN.     (Autlior's  sphygtii.  12  cm.) 

(1)  Puncture,  witli  rise  from  peripheral  irritation. 

(2)  Injection  of  adrenalin  chloride  (1  in  1,000),  lUx,  which  missed  the  vein. 


cardiac  or  vaso-motor  collapse.  In  fact  some  danger  seems 
possible  from  its  use  under  such  circumstances.  Ether,  as 
might  be  expected,  follows  the  same  rule.  The  wonderful 
peripheral  constrictor  action  of  adrenalin  is,  unfortunately,  so 


MctJx  a, v. 

One -hiC7>v1:e,  t.'rv'terva/^. 

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Fig,  58. — Extreme  eise  in  blood-pressuee  peodcced  by  the  inteavenous  injection 
OF  ADRENALIN.     (Author's  sphygHi.  12  cm.) 

(1)  Adrenalin  chloride  (1  in  1,000),  iTlxx,  injected  into  the  median  basilic  vein. 
"With  the  rise,  which  followed  instantly,  there  was  throbbing  in  head,  excitement,  sub- 
sternal pain,  and  nausea. 

(2)  No  pulse  palpable  ;  heart  sounds  very  faint;  patient  delirious,  pale. 
Strychnin  sulphate  gr.  ^/so  and  atropin  sulphate  gr.  ^/200  given  hypodermically. 

(3)  Caffein  sodium  salicylate,  gr.  ii,  given  hypodermically. 

In  spite  of  the  alarming  secondary  depression  (an  unusual  result),  there  were  no  bad 
after-effects. 


16 


•>26    BLOOD-PRESSURE   IX   INTERNAL   DISEASES 

fleeting  as  to  be  of  no  practical  semnce  in  acute  disease.  It 
must  also  be  injected  into  the  vein  to  act  at  all  (see  Figs.  57 
and  58) .  Crile  had  no  success  with  his  pneumatic  suit  in  a  few 
cases.  Probably  coincident  failm-e  of  the  respiratory  centre 
excludes  helj)  from  this  measure. 

d.  Late  Effects. — Thaj^er  has  examined  the  sj^stohc  blood- 
pressure,  as  well  as  the  condition  of  heart  and  arteries,  in  1G5 
persons  who  had  formerly  passed  through  typhoid  fever  in  the 
Johns  Hopkins  HosiDital.  His  figures  show  an  average  higher 
pressure  than  was  obtained  in  a  comparative  series  of  27G 
healthy  persons  who  had  not  had  the  disease,  either  when  ar- 
ranged by  decades,  or  for  the  entire  group.  What  is  much 
more  significant,  27  had  more  than  180  mm.  pressure,  while 
10  were  above  200  mm.  (R.  R.  5  cm.).  Of  the  normal  indi- 
viduals, only  one  woman  of  sixtj-  showed  a  tension  of  180 
mm.  Other  infections  and  possible  alcoholic  excesses  Avere 
excluded,  as  carefully  as  might  be,  from  the  list.  The  figures, 
with  Thayer's  other  findings,  seem  to  support  his  contention 
that  car dio -vascular  changes  frequently  follow  the  typhoid 
infection,  manifesting  themselves  more  especiall}'  in  later 
j'ears. 

B.  Pneumonia. — One  finds  little  uniformit}'  of  results  in  look- 
ing over  blood-pressure  charts  in  cases  of  pneumonia.  This 
holds  true  for  one  ^vriter  as  against  another,  and  for  many  ob- 
servers in  their  indi^-idual  experience.  The  explanation  is  evi- 
dently that  pneumonia  has  no  such  constant  effect  on  pressure 
as  tj'phoid  fever.  Potain  classes  it  as  a  disease  with  normal 
pressures,  Cook  and  Briggs,  and  Gilbert  and  Castaigne  as 
hypertensive,  while  Ha^'aski,  Kaufmann  and  de  Barj^  and 
Neisser  believe  the  pressure  is  usually  low.  Probably  the 
arterial  pressure  is  as  variable  as  man}-  of  the  other  clinical 
manifestations  of  the  disease. 

Fraenkel  has  made  regular  determinations  with  the  tonom- 
eter in  all  his  cases  for  some  years.  He  finds  a  subnormal 
pressure  the  rule,  especiall}'  at  the  time  of  the  crisis.  In  one- 
third  of  the  cases,  however,  it  was  absent.  He  does  not  attach 
much  value  to  the  tonometric  ol)servations.  Neisser,  also  with 
the  tonometer,  found  a  sharp  fall  at  the  crisis  frequent.  The 
instrument  seems  to  me  rather  ill  chosen  for  a  disease  in 
which  peripheral  cyanosis,  and  pro]ja])le  altered  tonus  of  the 


ACUTE   INFECTIOUS   DISEASES  227 

smaller  arteries,  is  so  common.  Giglioli  reports  50  cases  with 
the  Riva-Rocci  apparatus.  In  the  favoraVjle  ones  the  change 
in  pressure  was  slight.  In  severe  cases  he  saw  a  faU  to  80-90 
mm.  on  the  fourth  or  fifth  day.  In  fatal  cases  there  was  a 
rapid  fall,  he  says,  with  dilatation  of  the  heart.  Neither  Hen- 
sen,  nor  Mosen  could  demonstrate  the  critical  drop  in  pressure, 
while  Jarotzny's  lowest  recorded  reading  was  imder  just  these 
circumstances.  Gilbert  and  Castaigne,  while  their  figures  can- 
not be  accepted  on  accoimt  of  the  instrument  used  (P.),  yet 
agree  well  with  GigUoli.  They  found  shght  hypertension  during 
the  first  day  or  so.  In  favorable  cases  the  tension  never  de- 
creased materially,  while  in  fatal  cases  a  rapid  fall  to  80  mm. 
or  less  occurred.  During  convalescence  it  retiu-ned  slowly 
to  normal.  They  believe  that  a  drop  to  90  mm.  (P.)  signifies 
serious  danger.  My  personal  observations  are  not  numerous 
enough  to  allow  of  deductions.  There  seems  to  be  great 
daily  variation  in  pressure.  Nevertheless,  the  charts  have 
been  distinctly  helpful  as  a  guide  to  treatment,  the  general 
direction  of  the  pressure  and  pulse  curves,  not  their  absolute 
height,  being  the  valuable  feature.  A  rise  in  pressure  with 
fall  in  pulse,  as  improvement  set  in,  has  been  conspicuous  (see 
Fig.  33). 

When  one  pictures  the  possible  causes  for  variation  in  lobar 
pneumonia,  the  difference  in  individual  reaction  to  the  tox- 
aemia and  in  extent  of  limg  tissue  involved,  the  motor  restless- 
ness of  some  patients,  the  urgent  dyspnoea  of  others,  and  the 
great  hkehhood  of  an  asphyxial  rise  of  pressure  where  cyano- 
sis is  extreme,  there  is  httle  wonder  at  these  somewhat  discord- 
ant results.  Conditions  are  not  so  simple  as  in  the  pneiuno- 
coccus  septicsemia  of  Romberg  and  Passler.  However,  in 
pneumonia,  more  than  in  any  other  disease,  collapse  comes 
without  warning.  If,  in  even  a  portion  of  the  cases,  a  blood- 
pressure  chart  will  give  notice  of  its  approach,  the  chart  is 
worth  while.  This  is  the  more  true,  because,  in  this  disease, 
one  may  fight  for  even  minutes  with  the  hope  that  the  tide  will 
turn.  I  hope  to  make  observations  on  the  blood-pressure  reac- 
tion to  stimulation  of  the  nasal  mucosa,  which  in  man,  as  in 
the  rabbit,  may  give  a  much  earlier  indication  of  vaso-motor 
paralysis  than  the  actual  level  of  pressure.  The  treatment  of 
lobar  pneumonia  is  so  entirely  an  empirical  matter  that  I  can- 


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</) 

Fig.  59. — Fatal  lobar  pneumonia.     (Author's  sphygm.  12  cm.) 

Chart  from  J.  O'N.,  City  Hospital,  Ward  1.     Autopsy  showed  hepatization  of  entire 
right  lung  and  of  left  lower  lobe. 

(1)  Kise  in  pressure   as   muscular  twitching  became   marked;    probably  fictitious. 
Pulse  small. 

(2)  Sharp  rise  from  inti'avenous  saline  infusion. 

(3)  Rapid  fall  in  pressure,  with  rising  pulse,  beginning  twenty-four  hours  before 
death.     No  further  readings  possible. 

(4)  Diedat  10.20  p.m. 


230    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

not  enter  upon  it  from  the  standpoint  of  blood-pressure,  more 
than  to  repeat  what  has  already  been  said  under  typhoid  con- 
cerning stimulant  measures. 

C.  Diphtheria. — Only  a  few  clinical  studies  of  blood-pressure 
have  been  made  in  diphtheria.  The  most  extensive,  by  Fried- 
mann,  was  unfortunately  in  the  days  of  the  v.  Basch  sphyg- 
momanometer. Of  15  cases  in  his  series,  in  which  marked 
hypotension  came  on  during  the  first  week,  only  two  recov- 
ered. These  two  were  both  severe.  His  results  should  have 
further  confirmation  in  a  large  number  of  patients.  This  will 
only  be  possible  in  a  diphtheria  hospital,  but  is  most  desirable. 
In  laryngeal  diphtheria,  all  the  conditions  for  a  true  asphyxial 
elevation  exist.  This  was  seen  by  Shaw  and  carefully  studied 
by  Hensen.  One  girl,  for  example,  had  a  pressure  of  130  mm. 
(R.  R.  5  cm.)  and  no  respiratory  variation.  She  became  sud- 
denly cyanotic,  with  stridulous  breathing,  and  the  pressure 
rose  to  155  mm.,  with  each  inspiration  sinking  to  140  mm. 
Soon  the  breathing  became  free  again,  and  the  pressure  dropped 
at  once  to  130  mm.  This  blood-pressure  representation  of  the 
paradoxical  pulse  he  found  in  a  number  of  cases  of  laryngeal 
diphtheria. 

D.  Other  Acute  Infections  (Malaria ;  acute  rheumatism ;  septic 
conditions;  influenza). — In  none  of  the  other  acute  febrile  dis- 
eases is  there  anything  very  definite  about  the  state  of  the 
blood-pressure.  The  older  writers,  with  the  v.  Basch  instru- 
ment, studied  malaria  with  results  in  accordance  with  their 
particular  theory  as  to  the  relation  of  temperatm-e  to  blood- 
pressure.  N(^rris  recently  could  make  out  but  little  variation, 
in  spite  of  a  great  temperature  range.  Potain  sets  down  acute 
articular  rheumatism  as  a  hypotensive  disease,  but  Carter, 
Norris,  and  Ilensen  found  no  marked  change.  The  latter,  like 
Giglioli,  Hayaski,  and  Neisser,  found  that  in  most  febrile  dis- 
eases the  pressure  after  a  time  tended  to  become  subnormal. 
In  none  of  them  has  its  observation  been  shown  to  have  any 
great  use.  Hensen  studied  a  number  of  septic  conditions,  and 
Federn  lays  groat  stress  on  the  subnormal  pressure  in  epidemic 
influenza,  which  he  thinks  due  to  heart  weakness.  He  also 
says  that  persons  with  previous  hypertension  stand  the  disease 
badly.  Acute  peritonitis  will  be  considered  with  surgical  con- 
ditions in  Chapter  IX. 


CHRONIC   INFECTIOUS   DISEASES  231 

E.  Acute  Infections  in  Childhood.— Cook  has  made  important 
practical  studies  in  children  sick  with  acute  diarrhoeal  diseases, 
pneumonia,  pertussis,  and  tuberculosis,  as  well  as  in  marasmus 
and  rickets,  which  scarcely  belong  here.  In  all  these  condi- 
tions, falling  blood-pressure  was  found  almost  uniformly  as  an 
early  sign  of  a  change  for  the  worse,  a  rapid  drop  indicating 
serious  collapse.  The  decline  in  pressure  was  often  the  first 
evidence  of  trouble,  and,  in  his  experience,  constituted  the 
safest  guide  to  the  employment  of  stimulant  measures.  During 
the  first  year,  60  mm.  usually  marked  the  danger  line,  when 
treatment  was  called  for;  in  other  children,  80  mm.  The  gen- 
eral course  of  the  chart,  however,  was  more  valuable  than  any 
single  actual  reading.  In  collapse,  pressure  might  fall  30  mm. 
within  an  hour  or  so. 

a.  Therapeutics. — The  drugs  which  gave  the  best  results, 
judged  by  their  pressor  effects,  were  digitalin  and  strychnin, 
from  gr.  j^q  to  gr.  ^hii  especially  in  sudden  collapse.  Alcohol 
in  single  doses  was  without  constant  effect,  but  repeated  small 
doses  sometimes  caused  a  gradual  augmentation  of  tension. 
Saline  infusion,  as  a  stimulant,  was  worthless,  though  fre- 
quently acting  beneficially  on  the  general  condition,  perhaps 
through  the  elimination  of  toxins.  In  collapse  with  cyanosis, 
a  hot  mustard  bath  occasionally  worked  well.  A  short-lived 
response  to  treatment,  with  renewed  fall,  argued  a  bad  prog- 
nosis. 

3.    CHRONIC    INFECTIOUS    DISEASES 

A.  Tuberculosis.— The  earhest  studies  by  Marfan  led  him  to 
believe  that  low  tension  is  one  of  the  most  constant  symptoms 
of  phthisis,  appearing  even  in  the  incipient  stage.  Of  a  hun- 
dred patients,  only  three  showed  normal  pressure,  and  these 
were  old  people  with  arterio-sclerosis.  His  unqualified  state- 
ment may  find  some  explanation  in  the  fact  that  Potain's 
sphygmomanometer  would  be  likely  to  give  lower  readings  in 
thin  persons. 

Since  that  time,  systematic  observations  on  the  blood-pres- 
sure of  consumptives  have  been  published  from  several  Euro- 
pean sanitoria,  by  Burckhardt,  John,  and  Naumann,  all  with 
the  Gartner  tonometer.     A  number  of  isolated  measurements 


232    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 


of  less  value  are  given  by  Potain  (P.),  Jarotzny  (H.  &  B.), 
Hensen  (R.  R.),  and  Hayaski  (R.  R.  &  G.).  All  agree  that 
hypotension  is  the  rule  in  the  more  advanced  stages,  running 
roughly  parallel  with  the  impairment  of  general  bodily  vigor. 


A^r;(. 

3 

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Blood  Pressure 
Pulse  Rate. 

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90 

^        70 
60 
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30 
20 
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Fig.  00. — Marked  hypotension  in  acute  tubeuoulosis.     (Author's  sphyj^mi.  12  cm.) 

Potion  of  cliart  from  a  case  of  acute  plitliisis,  witli  terminal  jieueral  miliary  tuber- 
culosis (autopsy),  who  died  of  liieinorrIia<,'e,  April  13th,  ten  weeks  from  onset  of  disease. 
F.  I*.,  male,  ajred  twenty-nine,  ('ity  Hospital. 

Burckliardt,  in  rather  a  small  series,  found  the  pressure  regu- 
larly diminished  early  in  the  second  stage  of  the  disease,  and, 
in  advanced  phthisis,  rapid  pulse  and  subnormal  tension  were 
invariable.  Light  exercise  produced  a  rise  in  some  patients 
and  a  fall  in  others,  never  of  great  extent. 

Naumann  studied  100  cases,  from  which  all  who  had  fever, 
arterio-sclerosis,  heart  lesions,  pleural  adhesions,  or  albumin  or 
sugar  in  the  urine,  were  carefully  excluded.  They  were,  there- 
fore, patients  with  chronic,  practically  inactive  and  uncompli- 
cated pulmonary  tuberculosis.     In  this  they  differ  from  Burck- 


CHRONIC   INFECTIOUS   DISEASES 


233 


hardt's  patients,  most  of  whom  had  an  active  febrile  process. 
Of  these  100  patients, 

in  69  the  blood-pressure  was  over  130  mm.  (G.), 
in  13    "       "  "  "     115  to  130  mm.  (G.), 

in  18    "       "  "  "     under  115  mm.  (G.). 

Naumann  considers  these,  high,  normal,  and  subnormal  values. 
As  to  incidence  with  the  extent  of  the  pulmonary  lesion,  of  the 
69  patients  with  over  130  mm.,  there  were, 
in  1st  stage  (Turban),  28, 
in  2d       "  "  22, 

in  3d       "  "  19. 

Evidently  the  area  of  lung  involved  is  without  influence.     In 
order  to  reconcile  these  results  with  the  apparently  uniform 


MaT>cK 

<ao 

3,/ 

2.2 

Blood  Pressure. 
Pulse  Rate. 

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30 
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l^a,^ 

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— 

Fig.  61. — Chronic  pulmonary  tuberculosis  with  slight  hypotension. 
(Author's  sphygm.  12  cm.) 

Portion  of  chart  from  J.  L.,  male,  aped  sixty-three,  City  Hospital.  Advanced  process 
■with  fever.     Patient  died  April  22d,  with  marked  hypotension. 

This  chart  represents  the  usual  course  of  blood-pressure  in  such  cases  until  near  the 
end,  when  hypotension  becomes  marked. 


234    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

hypotension  of  the  advanced  febrile  cases,  one  must  suppose 
that  chronic  toxsemia  is  its  probable  cause.  Naumann  believes 
that  arterial  tension  is  valuable  in  prognosis,  as  showing  to 
some  extent  the  constitutional  disturbance,  which  is  unques- 
tionably a  better  guide  to  the  future  than  the  local  signs. 

For  treatment,  it  is  hard  to  see  that  a  knowledge  of  the 
blood-pressure  adds  much,  save  that  a  continuously  low  level 
is  additional  argument  against  physical  exertion.  The  general 
causes  of  low  pressure,  the  toxsemia  and  mahiutrition,  with 
their  results  in  heart  and  skeletal  muscles,  are  the  proper  ob- 
jects of  therapeutic  attack,  not  the  circulatory  system. 

a.  Haemoptysis. — Burckhardt  quotes  a  case,  which  he  tries  to 
bring  in  line  with  Hensen's  observations  on  haemoptysis  from 
aneurism,  and  hsematemesis,  as  showing  a  rise  in  pressure  after 
haemoptysis.  From  his  own  figures,  8.5  cm.  before,  7.5  cm, 
the  next  morning,  10  cm.  the  second  day,  there  was  a  primary 
fall.  His  determinations  were  at  too  great  an  interval  to  be 
valuable.  If  the  pressure  does  rise  during  a  haemorrhage,  as 
Hensen  showed  it  might,  I  am  inclined  to  look  for  the  reason 
in  the  attendant  psychical  excitement.  Certainly  in  surgical 
operations  and  in  typhoid  fever,  where  the  mental  factor  is 
absent,  a  fall  in  pressure  is  practically  invariable.  Schiile  re- 
ports hypotension  after  haemoptysis,  as  low  as  60  mm.  (G.), 
and  Cook  and  Briggs  show  a  fall  from  125  to  70  mm.,  due  to 
a  haemorrhage  of  1,100  c.c.  Naumann  attempts  to  correlate  the 
higher  tension  in  09  of  his  cases  with  the  tendency  to  haemop- 
tysis. Of  51  patients  who  had  bleeding  at  some  time,  80.2  per 
cent,  showed  a  pressure  above  130  mm.  Of  these  44  with 
hypertension  (V)  and  haemoptysis,  24  were  in  the  early  stage. 
From  this  he  concludes  that  most  haemoptyses  occur  in  the 
early  cases  with  high  blood-pressure.  These  results  need  con- 
firmation. 

B.  Syphilis. — It  is  not  my  purpose  to  discuss  in  any  way  the 
relation  of  a  past  syphilitic  infection  to  those  late  anatomical 
changes  in  heart  and  vessels,  which  have  already  been  consid- 
ered. In  the  early  stages  of  syphilis,  however,  when  the  process 
clinically  resembles  a  subacute  or  chronic  infectious  disease, 
circulatory  disturbances  are  frequent.  These  usually  show  as 
minor  grades  of  cardiac  insufficiency,  with  the  development  of 
a  mitral  systolic  murmur.     Grassmann  has  studied  the  blood- 


DISEASES   WITH   IMPAIRED   NUTRITION      235 

pressure  in  G4  such  cases,  making  repeated  observations  in  61, 
with  the  V,  Basch  sphygmomanometer.  In  nearly  all  of  them 
he  found  hypotension  more  or  less  marked.  Eighty  per  cent, 
had  a  pressure  below  80  mm.  (right  temporal  artery)  at  the 
beginning  of  treatment. 

The  behavior  of  the  blood-pressure  during  the  further  course 
of  the  disease  varied.  Twelve  cases  showed  no  change,  while 
48  had  considerable  fluctuations.  Of  these,  the  majority  pre- 
sented a  further  fall  in  pressure  averaging  15  to  20  mm.,  devel- 
oping a  little  time  after  the  institution  of  mercurial  treatment. 
As  a  rule  the  haemoglobin  was  simultaneously  reduced.  In  37 
patients  with  subnormal  initial  tension,  7  showed  a  further 
lowering;  9,  a  sinking,  followed  by  a  rising  pressure;  17,  a 
rise;  and  4,  a  rise  with  subsequent  fall.  For  the  entire  61 
patients,  the  results  of  treatment  were  as  follows:  stationary 
pressure,  13  cases;  an  increase,  temporary  or  sustained,  22 
cases ;  a  decrease,  26  cases, 

Grdfesmann  believes  that  the  relatively  small  number  of  pa- 
tients in  whom  the  blood-pressure  remains  normal  during  early 
syphilis  are  an  indication  of  the  frequency  with  which  damage 
to  the  heart,  of  greater  or  less  extent,  occurs  at  this  stage.  He 
considers  the  hypotension  a  sign  of  relative  insufficiency  of  the 
left  ventricle.  Unfortunately,  improvement  in  the  cardiac 
condition,  as  shown  by  the  disappearance  of  relative  mitral 
insufficiency,  sometimes  coincided  with  an  increase,  sometimes 
with  a  reduction  of  tension. 

4.    CHRONIC    DISEASES   ASSOCIATED   WITH 
IMPAIRED    NUTRITION 

For  convenience  it  is  necessary  to  include  under  this  head- 
ing a  somewhat  heterogeneous  group.  The  blood-pressure 
findings  are  of  no  special  importance  in  any  of  them,  except  as 
pointing  to  unnoticed  complications  from  the  side  of  kidneys, 
heart,  or  arteries. 

A.  Diabetes. — Potain  laid  much  stress  on  diabetes  as  a  cause 
of  the  extreme  grade  of  hypertension.  His  dictum  seems  to 
have  been  accepted  by  many  other  observers  without  verifica- 
tion. Certainly  there  exist  no  satisfactory  statistics  on  the 
subject,  and  even  isolated  observations  are  hard  to  fold.  Crum- 
mer,  for  instance,  noted  high  pressure.     On  the  other  hand 


236    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

Hensen,  in  his  Table  III,  headed  Cachexia  and  Marasmus,  in- 
cludes two  cases  of  diabetes  with  slight  hypotension.  I  have 
seen  both  high  and  low  blood-pressure  in  diabetes,  the  latter  in 
severe  cases  with  marked  emaciation  and  diacetic  acid  in  the 
urine ;  the  former  especially  in  the  milder  forms  in  stout  elderly 
people,  where  chronic  nephritis  or  arterio-sclerosis  existed.  I 
believe  that  the  disease,  of  itself,  is  without  influence  on  arte- 
rial pressure ;  that  the  occurrence  of  chronic  nephritis,  or  arte- 
rio-  or  angio-sclerosis,  as  a  complication,  explains  the  h^^per- 
tension ;  and  that  the  resultant  emaciation,  and  brown  atrophy 
or  fatty  change  in  the  heart,  cause  the  hypotension  in  severe 
cases.  Tabulated  observations  on  a  large  number  of  cases, 
with  careful  notes  of  the  complicating  conditions,  will  settle 
this  still  open  question. 

B.  The  Ansemias. — The  condition  of  the  arterial  pressure  in 
anaemia  has  been  a  matter  for  considerable  discussion,  espe- 
cially since  many  authors,  who  use  the  sphygmogi-aph  as  an 
instrument  of  precision,  have  insisted  on  the  occurrence  of  pro- 
longed tension.  Almost  all  the  measurements  of  blood-pressure 
in  anaemic  states  are  against  this  view.  As  a  matter  of  fact, 
the  hj'potension  of  cachectic  states  is  present  in  most  of  the  sec- 
ondary ansemias,  and  the  causes  of  hypertension  may  coexist 
with  others,  chronic  nephritis  especially.  Chlorosis  is  the  form 
in  which  the  effect  of  haemoglobin  deficiency  per  se  should  be 
demonstrated.  The  general  consensus  of  opinion  seems  to  be 
that  some  reduction  of  pressure  exists  in  chlorotics,  but  it  is 
neither  marked  nor  proportional,  in  any  but  the  roughest  way, 
to  the  grade  of  anaemia  present.  I  cannot  see  that  blood-pres- 
sure measurements  add  anything  valuable  to  our  clinical  knowl- 
edge of  the  anaemias.  They  are  useful  mainly  as  indicating 
possible  complications,  or  primary  causative  conditions  in  the 
case  of  the  secondary  varieties. 

V.  Basch  originally  taught  that  aiipcmia  is  associated  with  low  arterial 
pressure.  Bihler  studied  the  relation  of  pressure  and  haemoglobin  in  50 
chlorotic  girls.  The  average  hnsnioglobin  on  admission  was  58  per  cent., 
systolic  pressure  77  mm.  (v.  B.)  ;  on  discharge,  94  per  cent,  and  86  mm. 
This  difference  lies  within  the  possible  error  of  the  method,  but,  in  50 
cases,  may  be  accorded  some  value.  He  believed  it  was  related  to  the 
cai'diac  weakness,  so  common  in  chlorosis.  Potain  considered  chlorosis  a 
disease  with  normal  pressures.     Carter,  and  Jarotzny,  both  found  low  ten- 


DISEASES   WITH   IMPAIRED   NUTRITION      237 

sion  (H.  &  B.).  Witli  the  tonometer,  Scbiile,  and  Crummer  saw  low  pres- 
sures, the  hitter  some  very  low  readings.  Shaw,  however,  in  children,  said 
tension  was  slightly  increased.  With  the  Eiva-Eocci,  Giglioli  examined 
30  anasmias  of  different  origins,  all  having  hypotension,  the  lowest,  70 
mm.,  a  pernicious  anasmia.  Cook  and  Briggs  believe  hypotension  is  the 
i-ule,  but  dependent  more  on  the  state  of  general  nutrition  than  on  the 
blood  condition.     Hensen  saw  little  change,  but  examined  veiy  few  cases. 

C.  Cachectic  States. — The  extreme  impairment  of  nutrition 
which  we  call  cachexia,  is  unquestionably  associated  with  hypo- 
tension in  the  majority  of  cases.  Both  v.  Basch  and  Potain 
were  convinced  of  this,  and,  with  the  newer  instruments.  Cook 
and  Briggs  (R.  R.),  and  Schiile  (G.),  among  others,  have  sub- 
stantiated it.  Cases  of  cancer,  especially  of  the  digestive  system, 
of  advanced  tuberculosis,  of  syphilitic  cachexia,  etc.,  have  a 
blood-pressure  more  or  less  in  accord  with  their  general  state  of 
nutrition  (see  Fig.  60) .  The  lowest  reading  I  have  ever  seen  in 
office  practice  was  in  a  patient  with  cancer  of  the  oesophagus, 
whose  strength  was  still  fair.  SystoHc  pressure  was  80  mm., 
diastolic,  55  mm.  (J.  12  cm.).  Marked  hypotension,  however, 
that  is,  below  80  mm,  (5  cm.),  70  mm.  (12  cm.),  does  not  occur 
except  as  a  terminal  event. 

Hensen  calls  attention  to  a  fact,  which  I  believe  is  too  often 
lost  sight  of,  to  wit,  that  even  profound  malnutrition  may  be 
associated  with  a  comparatively  high  arterial  pressure.  He 
cites  one  case  of  stenosis  of  the  oesophagus  with  arterio- 
sclerosis, who  showed  a  systolic  pressure  of  183  mm.  (R.  R.  5 
cm.).  One  must  always  remember  that  cardio- vascular  disease 
with  high  tension  may  coexist  in  these  cases,  though  probably 
the  pressure  does  not  reach  the  figures  it  would,  were  the  gen- 
eral health  better. 

a.  Addison's  Disease. — I  call  attention  to  two  observations  of 
my  own  in  this  connection,  because  it  is  usually  believed  that 
extreme  hypotension  goes  with  the  disease.  One  was  a  woman 
who  was  still  about,  but  with  a  typical  clinical  picture  of  Ad- 
dison's and  a  diastolic  pressure  of  90  mm.  (H.  &  B.);  the  so- 
called  mean  pressure  was  105  mm.  The  other,  a  man  in  my 
service  at  the  City  Hospital,  was  in  the  last  stages  of  emacia- 
tion and  asthenia,  and  showed  at  autopsy  typical  fibrosis  and 
caseation  of  both  suprarenals.  A  number  of  determinations, 
up  to  within  about  two  weeks  of  his  death,  showed  a  systohc 


238    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

pressure  of  140  mm.  in  one  arm.     In  the  other,  the  radial  was 
exceedingly  small  and  systolic  pressure  was  about  100  mm. 

5.    MISCELLANEOUS 

Only  conditions  which  are  important,  or  in  which  we  have 
actual  knowledge  of  the  blood-pressure,  are  included  here.  The 
results  of  notoriously  inaccurate  methods  or  of  a  priori  reason- 
ing, which  one  meets  in  the  literature,  will  not  be  considered. 

A.  Lead  Poisoning. — Chronic  lead  intoxication,  as  is  well 
known,  frecpiently  produces  changes  in  arteries  and  kidneys, 
and  thus  permanent  hypertension  as  a  secondary  effect.  Apart 
from  such  anatomical  alterations,  however,  lead  poisoning,  as 
evidenced  by  the  typical  colic,  almost  alwa3"S  goes  with  mod- 
eratel}^  high  blood-pressure.  Christeller,  Hensen  (8  out  of  10 
cases),  Norris  (8  out  of  9  cases),  and  Thaussig  (3  cases),  report 
this  as  the  rule.  Hensen,  and  Norris,  in  isolated  cases,  espe- 
cially with  intoxications  of  short  duration,  failed  to  obtain  this 
hypertension  ;  and  Gumprecht,  and  Butterman  note  normal 
pressures  for  a  case  or  so. 

Borgen  made  the  most  careful  study  of  the  condition,  in  a 
series  of  19  patients,  unfortunately  with  the  v.  Basch  sphyg- 
momanometer. From  the  figures  obtained  he  divides  the  clin- 
ical course  of  lead  colic,  as  seen  after  admission  to  a  hospital, 
into  four  stages. 

1.  Stage  of  rising  pressure,  duration  indefinite,  twelve  hours 
to  several  days. 

2.  Stage  of  high  pressure,  one  to  four  days,  or  longer.  The 
pressure  remains  equally  high  during  and  between  the  attacks 
of  pain,  which  have  already  begun  in  the  first  stage. 

3.  Stage  of  falling  pressure.  Pain  and  tenderness  disapi)ear 
rapidly,  appetite  and  bowels  become  normal.  Pressure  sinks 
slowly  to  normal  during  a  day  or  two. 

4.  Stage  of  subnormal  pressure.  Not  present  in  all  patients. 
On  discharge,  pressure  usually  above  the  average,  but  may  be 
below. 

B()rg(>n  found  no  relation  between  the  actual  paroxysms  of 
pain  and  the  hypertension,  which  was  contimious.  Morphin 
seemed  to  reduce  the  tension  slightly.  Thaussig  reports  some 
remarkable  effects  from,  or  coincident  witli,  treatment  with 
iodipin,  administered  hypodermatically  in  doses  of  5  c.c,  in- 


MISCELLANEOUS  239 

creased  to  15  c.c.  One  case,  in  twenty-eight  days,  dropped  from 
220  mm.  (G.)  to  110  mm.,  with  improvement  in  all  symptoms; 
another  in  ten  days,  from  200  mm.  to  90  mm. ;  the  third,  in 
eight  days,  from  IGO  mm.  to  80  mm. 

Pal  reports  a  case  of  unusual  interest,  in  which  the  amau- 
rosis, occasionally  seen  in  lead  colic,  seemed  to  stand  in  direct 
relation  to  the  hypertension. 

The  patient,  a  man  of  foi'ty-one,  was  admitted  to  the  clinic  on  tlie  sixtli 
day  of  a  typical  attack,  having  i:)assed  through  a  similar  one  three  years 
previously.  On  admission,  pressiire  was  160  mm.  (G.),  i^uLse  78.  Eye- 
sight and  pupillary  reactions  were  normal.  The  abdomen  was  retracted 
and  tender,  and  the  patient  comj)lained  of  considerable  jiain.  Neither 
fseces  nor  wind  were  passed.     Urine  contained  neither  albumin  nor  sugar. 

On  the  next  morning  the  patient  noticed  impairment  of  vision,  which 
increased  to  complete  amaurosis  during  the  day.  Headache  occurred.  The 
pupil  was  normal,  papilla  pale,  vessels  tortuous,  otherwise  a  normal  oijli- 
thalmoscopic  picture.  Tonometer  reading  170  mm.  in  the  morning,  180 
mm.  in  the  evening.  He  was  ordered  5  grams  of  potassium  iodide  per 
day.  The  subsequent  day  the  patient  could  distinguish  between  light 
and  darkness.  Pain  was  less,  and  a  good  movement  followed  the  use  of 
senna.  Pressure,  a.  m.  165  mm.,  p.m.  IGO  mm.  A  day  later  he  could  count 
fingers,  and  pain  had  disappeared.  Pressure  145  mm.  In  one  day  more 
vision  was  restored,  and  the  tension  had  fallen  to  125-120  mm.  Recov- 
ery was  rapid  and,  on  the  day  of  discharge,  his  pressure  was  only  75  mm. 

Altogether  it  seems  proven  that  lead  must  be  kept  in  mind 
as  a  possible  cause  of  marked  hypertension,  in  cases  without 
demonstrable  nephritis  or  arterio-sclerosis.  While  it  is  not  in- 
variable, the  other  diagnostic  features,  blue  line  and  granular 
degeneration  of  the  red  blood  cells,  are  also  lacking  in  some 
patients,  so  that  the  sphygmomanometer  ma}'"  assist  in  the 
decision  of  an  obscure  case. 

B.  Gout. — Clinicians  have  been  accustomed  to  associate  high 
pulse  tension  and  gout,  yet  no  sphygmomanometric  observa- 
tions have  yet  been  reported  which  can  be  accepted.  Jourdin 
and  Fischer  state  that  in  gout,  which  is  a  hypertensive  disease, 
a  fall  in  pressure  presages  an  acute  attack,  but  do  not  quote 
their  authority.  It  is  to  be  hoped  that  we  may  have  some 
objective  testimony  soon,  for  it  would  be  of  distinct  theoretical 
importance  in  connection  with  the  etiological  factors  in  arterial 
disease,  and  the  relation  of  the  latter,  and  of  nephritis,  to 
gout. 


240    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

C.  Emphysema;  Chronic  Bronchitis;  Asthma. — Very  little  at- 
tention has  been  paid  to  these  conditions,  in  which  dyspnoea  is 
so  marked  a  feature.  Hensen  alone  has  more  than  a  passing 
reference  to  them,  Carter,  and  Norris  merely  noting  a  case  or 
so  with  fairly  normal  pressure.  Hensen  regularly  found  com- 
parativelj^  high  tension  (135  to  180  mm.  R.  R.  5  cm.),  in  out- 
patients with  emphysema,  asthma,  and  kyphoscoliosis.  This 
has  been  my  experience  in  office  practice,  where  no  clinical 
evidence  of  nei^hritis  or  arterial  change  existed.  In  many  of 
my  cases  I  am  inclined  to  think  of  latent  angio-sclerosis  as  the 
probable  cause,  since  arterial  disease  and  emphysema  are  fre- 
quent companions  at  the  autopsy  table.  Hensen  thought  the 
dyspnoea  was  the  causative  factor  ;  but  the  arterial  pressure 
may  be  permanently  high,  while  dyspncea  only  follows  exer- 
tion. One  patient,  with  advanced  emphj^sema,  following 
many  years  of  chronic  bronchitis  with  asthma,  had  a  systolic 
pressure  of  140  mm.,  diastolic  110  mm.  (J.  12  cm.),  in  spite  of  a 
dilated  right  heart  with  tricuspid  systolic  murmur,  and  oedema 
of  the  legs.  Such  cases  show  well  the  futility  of  judging  the 
condition  of  the  heart  from  the  height  of  blood-pressure. 

In  asthma,  Hensen  repeatedly  observed  elevations  in  ten- 
sion of  20  mm.  and  more  at  the  approach  of  an  attack.  Also, 
during  the  paroxysm,  marked  inspiratory  sinking  of  pressure. 
Nervous  influences,  as  well  as  the  dyspnoea,  must  be  in  mind 
in  such  a  distressing  condition  as  spasmodic  asthma. 

D.  Pleural  and  Peritoneal  Effusions. — A  small  number  of 
blood-pressure  determinations,  before  and  after  the  removal  of 
pleural  and  peritoneal  effusions,  show  a  constant  fall  as  the 
result  of  the  procedure.  Hensen,  Kapsammer,  and  Norris  re- 
port cases.  The  effect  is  much  more  marked  in  the  case  of 
largo  pleural  than  of  peritoneal  collections,  and  evidently  in- 
dicates that  the  presence  of  the  fluid  causes  functional  hyper- 
tension. 

Quirin  has  examined  the  intra-abdominal  pressure  during 
the  drainage  of  ascitic  fluid,  and  found  positive  pressures  at 
the  moment  of  puncture  between  14  and  2S  mm.  Hg.  With 
the  removal  of  the  fluid,  this  sank  gradually,  4  mm.  being  the 
lowest  and  14  mm.  the  highest  figures  at  the  end  of  paracen- 
tesis. This  fall  in  intra-abdominal  ])ressure  of  10  to  14  mm. 
corresponds  closelj'  with  the  reduction  in  systolic  arterial  ten- 


MISCELLANEOUS  241 

sion  reported  during  the  same  procedure,  usually  only  5  to 
9  mm.  In  the  light  of  Quirin's  animal  experiments  (see 
page  15),  a  simple  mechanical  increase  in  peripheral  resist- 
ance obviously  suffices  to  explain  this  slight  hypertension. 
Cook  and  Briggs  note  a  larger  reduction  on  tapping  an  ascitic 
accumulation. 

With  the  aspiration  of  large  pleural  accumulations,  much 
greater  differences  occur.  Hensen's  results,  in  7  cases,  show 
l-i  mm.  as  the  least,  50  mm.  as  the  greatest  reduction  in  sys- 
tolic pressure.  The  mechanical  factor  is  inadequate  to  explain 
such  considerable  hypertension,  and  we  must  think  either  of 
reflex  vaso-constriction  or,  as  Hensen  suggests,  of  a  mild  as- 
phyxial  effect.  Both  may  occur.  The  only  specific  references 
to  pleurisy  with  effusion,  which  ignore  this  hypertensive  effect, 
are  from  the  French  observations  with  Potain's  sphygmoma- 
nometer, or  still  more  inaccurate  instruments.  Jourdin  and 
Fischer  go  so  far  astray  as  to  give  hypotension  as  an  indica- 
tion for  aspiration. 

The  chief  practical  value  in  knowing  that  pleural  effusions 
tend  to  raise  arterial  pressure  considerably  is,  that  hydrothorax 
frequently  complicates  nephritis  and  cardiac  disease.  One 
must  not  refer  a  lower  tension  after  aspiration  to  the  other 
therapeutic  measures ;  nor,  in  an  obscure  case  of  cardiac  disease 
with  albuminuria  and  fluid  in  the  chest,  think  that  hyperten- 
sion proves  the  existence  of  true  chronic  nephritis. 

E.  Haemorrliage. — Apart  from  typhoid  fever,  in  which  hsem- 
orrhage  seems  regularly  accompanied  by  hypotension,  bleeding 
is  seen  by  the  internal  physician  most  commonly  as  haemopty- 
sis or  epistaxis,  then  from  the  rectum,  from  gastric  or  duode- 
nal ulcers,  and  occasionally  from  the  rupture  of  an  aneurism. 
Hensen  reports  some  seemingly  paradoxical  findings  in  a  case 
of  aneurism,  which  perforated  the  left  bronchus  and  gave  rise 
to  repeated  haemoptysis,  and  in  gastric  and  pulmonary  haem- 
orrhages, 11  cases  in  all.  In  most  of  these  the  systolic  tension 
was  increased  immediately  after  copious  bleeding,  sometimes 
20  to  25  mm.  above  its  previous  level.  Later  there  was  a 
gradual  fall,  never  to  real  subnormal  figures,  with  subsequent 
return  to  the  original  reading  after  a  few  days. 

While   the   physiologists    have    taught   us   not  to   expect 

marked  or  permanent  effects  on  blood-pressure  from  loss  of 
17 


243    BLOOD-PRESSURE  IN   INTERNAL   DISEASES 

blood  (see  page  2G),  still  an  initial  rise  does  not  tally  either 
with  animal  experiment,  surgical  observation,  or  the  findings 
in  t^^phoid  fever.  Two  possible  causes  for  this  difference  in 
the  two  groups  of  conditions  are  evident  to  me.  One  is  the 
great  mental  excitement  which  attends  the  knowledge  of 
bleeding  on  the  part  of  the  patient,  and  which  to  me  seems 
the  likeliest  source  of  the  initial  rise  in  pressure.  Neither  in 
anaesthetized  animals  or  men,  or  in  typhoid,  does  mental  per- 
turbation occur.  The  other  cause  is,  perhaps,  the  state  of  the 
vaso-motor  system,  which  in  operations  and  in  severe  infec- 
tions has  not  its  usual  power  of  response,  and  might  allow 
a  greater  fall  in  pressure  than  would  occur  under  more  normal 
circumstances.  A  large  number  of  cases  must  be  studied, 
with  careful  noting  of  the  psychical,  as  well  as  the  physical 
results  of  the  haemorrhage,  before  we  shall  be  in  a  position  to 
understand  its  effects  on  blood-pressure.  Records  of  systohc 
and  diastolic  pressures  will  have  the  greatest  value. 

LITERATURE 

Alezais  et  Francois.     La  tension  art6rielle  dans  la  fievre  typboide.     Rev. 

de  Med.,  1899,  vol.  xix,  p.  88. 
V.   Basel),  S.     Einige  Ergebnisse  der  Blntdruckmessnug  an   Gesunden 

nnd  Kranken.     Zeitschr.  f.  klin.  Med.,  1881,  vol.  iii,  p.  502. 
Bihler.     Ueber  das  Veibalten  des  Blutdnicks  bei  Chloiotisclien  nnd  iiber 

die  bei  denselben  vorkommenden  Storungen  am  Herzeu.     Deutscli. 

Arch.  f.  klin.  Med.,  1894,  vol.  Iii,  p.  281. 
Borgen,    Thomas.      Blutdruckbestimmnngen    bei    Bleikolik.      Deutsch. 

Arch.  f.  klin.  Med.,  1895,  vol.  Ivi,  p.  248. 
Briggs,  J.  B.     A  Note  on  the  Association  of  a  Rise  in  Systolic  Blood- 
pressure  witli  the  Onset  of  Perforative  Peritonitis  in  Tyi)hoid  Fever. 

Boston  Med.  and  Surg.  Jour.,  1903,  vol.  cxHx,  p.  M3. 
Burckhardt,  M.     Untersuchungen  iiber  Blutdruck  und  Puis  bei  Tuber- 

kulosen  in  Davos.     Deut.sch.  Arch.  f.  klin.  Med.,  1901,  vol.  Ixx,  p.  236. 
Butterman.     Einige  Beobachtungen  fiber  das  Verhalten  des  Blntdrucks 

bei  Kranken.     Deutsch.  Arch.  f.  klin.  Mod.,  1902,  vol.  Ixxiv,  p.  1. 
Cabot,   R.  C.     Studios  on  the  Action  of  Alcohol  in  Disease,  especially 

upon  the  Circulation.     Med.  News,  1903,  vol.  Ixxxiii,  p.  145. 
Christeller.      Ueber   lilutdruckmessungen    an    Menschen  unter  patholo- 

gischen  Veihaltnissen.     Zeitschr.  f.  klin.  Med.,  1881,  vol.  iii,  p.  33. 
Cook,  H.  W.     The  Clinical  Value  of  Blood-pressure  Determinations  as  a 

Guide  to  Stimulation  in  Sick  Children.     Am.  Jour,  of  the  Med.  Sci., 

1903,  vol.  cxxv,  p.  433. 


MISCELLANEOUS  243 

Cook,  H.  W. ,  and  Briggs,  J.  B.     Clinical  Observations  on  Blood-pressure. 

Jolins  Hopkins  Hosp.  Eep.,  1903,  vol.  xi,  p.  451. 
Crile,  G.  W.     Diagnostic  Value  of  Blood-pressure  Determinations  in  the 

Diagnosis  of  Tyishoid  Perforations.     Jour,  of  the  Amer.  Med.  Asso., 

1903,  vol.  xl,  p.  1292. 
Crurumer,  Le  Koy.     On  the  Use  of  Gartner's  Tonometer.     Med.  Herald, 

St.  Joseph,  Mo.,  1902,  vol.  xxi,  p.  46. 
Fedem,   S.     TJeber  Influenza.     Wien.  med.  Wochenschr. ,  1901,  vol.   li, 

p.  1162. 
Friedmann,  J.  H.    Blutdruckmessungen  bei  Dii)htherie.    Jahrb.  f.  Kinder- 

heilkunde,  1893,  vol.  xxxvi,  ip.  50. 
Giglioli,  G.  Y.     Alcune  critiche  e  alcune  richerche  di  sfigmomanometria 

clinica.     Riv.  crit.  di  clin.  Med.,  1900,  vol.  i,  pp.  625  and  641. 
Gilbert,  A.,  et  Castaigne,  J.     La  tension  arterielle  dans  les  pneumonies. 

Sean,  et  Mem.  de  la  Soc.  de  Biol.,  1899,  vol.  i,  p.  633. 
Grassmann,  K.     Klinische  Untersuchungen  an  den  Kreislaufsorganen  im 

Friihstadium  der  Syphilis.     Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol. 

Ixix,  p.  264.     (See  pp.  281-289.) 
Gumprecht.     Experimentelle  und  klinische  Priifung  des  Riva-Eocci'schen 

Sphygmomanometers.      Zeitschr.   f.    klin.    Med.,    1900,   vol.    xxxix, 

p.  377. 
Hayaski,    T.     Vergleichende     Blutdruckmessungen    an    Gesunden    und 

Kranken    mit   den   Apparaten  von   Gartner,  Eiva-Rocci   und  Frey. 

Inaug.  Dissert.,  Erlangen,  1901. 
Hensen,  H.     Beitrage  zur  Physiologic  und  Pathologic  des  Blutdmcks. 

Deutsch.  Arch.  f.  klin.  Med.,  1900,  vol.  Ixvii,  p.  4.38. 
Jarotzny,  A.    Zur  Methodik  der  klinischen  Blutdruckmessung.    Centralbl. 

f.  in.  Med.,  1901,  vol.  xxii,  p.  599. 
John,  Max.    Ueber  den  arteriellen  Blutdruck  der  Phthisiker.    Zeitschr.  f. 

diiit.  u.  phys.  Therap.,  1902,  vol.  v,  p.  275. 
Jourdin,  Ch.,  et  Fischer,  G.     De  Timportance  pronostique  et  therapeu- 

tique  de  la  pression  arterielle.     Eev.  de  Med.,  1902,  vol.  xxii,  p.  945. 
Kapsammer,  Geo.     Blutdi-uckmessungen  mit  dem   Giirtner'schen  Tono- 
meter.   Wien.  klin.  Wochenschr.,  1899,  vol.  xii,  p.  1279. 
Kaufmann,  J.,  und  de  Bary,  W.     Ueber  die  Einwirkungen  Priessnitz'scher 

Einwickelungen  auf  den   Blutdnick  bei  crouposer  Pneumonic  und 

diflfuser  Nephritis.     Berl.  klin.  Wochenschr.,  1888,  vol.  xxv,  p.  557. 
Marfan,  M.  C.  B.    De  I'abaissement  de  la  tension  arterielle  dans  la  phthisic 

piiluionaire.     La  Semaine  Med.,  1891,  vol.  xi,  p.  213. 
Mercandino,  F.     Ueber  den  Einfluss  einiger  Herzstiniulantien  und  ein- 

zelner  hydriatischer  Proceduren  auf  den  Blutdruck  im  Verlaufe  der 

akuten    Infectionskrankheiten.      Blatter    f.  klin.    Hydrother.,    1900, 

vol.  X,  p.  241. 
Mosen,  R.     Ueber  das  Verhalten  des  Blutdrucks  im  Fieber.     Deutsch. 

Arch.  f.  klin.  Med.,  1894,  vol.  lii,  p.  600. 


244    BLOOD-PRESSURE   IN   INTERNAL   DISEASES 

Naumann,    H.     Blutdruckmessungen    an    Lungenkranken.     Zeitschr.   f. 

Tuberkulose,  1903,  vol.  v,  p.  118. 
Neisser.     Ueber   Blutdrnckmessung  am  Krankenbett.     Beii.  kliu.  Wo- 

chenschr.,  1900,  vol.  xxxvii,  p.  557. 
Norris,  G.  W.    A  Contributiou  to  the  Study  of  the  Human  Blood-pressure 

in  some  Pathological  Conditions.     Am.  Jour,  of  the  Med.  Sci.,  1903, 

vol.  cxxv,  p.  888. 
Passler,  H.     Experimentelle  Uutersuchungen  iiber  die  allgemeine  Thera- 

pie  der  Kreislaufstorung  bei  acuteu  Infectionskrankheiten.     Deutsch. 

Arch.  f.  klin.  Med.,  1899,  vol.  Ixiv,  p.  715. 
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logique.     Paris,  1902. 
Quirin,  A.     Ueber  das  Verhalten  des  normalen  und  pathologisch  gestei- 

gerten   intraabdominalen   Drucks   und   seine   Riickwirkung  auf   die 

arterielle  Blutcirculation.     Deut.sch.  Arch.  f.  klin.  Med.,  1901,  vol. 

Ixxi,  p.  79.     (See  pp.  99-102.) 
Schiile.     Ueber  Blutdruckmes.sungen  mit  dem  Tonometer  von  Gartner. 

Berl.  klin.  Wochenschr.,  1900,  vol.  xxxvii,  p.  726. 
Shaw,  H.  L.  K.    Arterial  Tension  in  Childhood.    Albany  Med.  Ann.,  1900, 

vol.  xxi,  p.  88. 
Thaussig,  R.    Zur  Kenntniss  der  Gefasswirkung  des  lods  (bezw.  lodipin). 

Wien.  med.  Wochenschr.,  1902,  vol.  lii,  p.  1399. 
Thayer,  W.  S.     On  the  Late  Effects  of  Typhoid  Fever  on  the  Heart  and 

Vessels.     Am.  Jour,  of  the  Med.  Sci.,  1904,  vol.  cxxvii,  p.  391. 


CHAPTER  VIII 
BLOOD-PRESSURE   IN  NERVOUS  AND   MENTAL  DISEASES 

1.  Diseases  of  the  spinal  cord. 

A.  Tabes  dorsalis. 

2.  Diseases  of  the  brain. 

A.  Vascular  diseases. 

a.  Cerebral  haemorrhage. 

b.  Cerebral  thrombosis  and  embolism. 

B.  Tumors  and  inflanunations. 

C.  General  paresis. 

D.  Myasthenia  gravis. 

3.  The  psychoses. 

A.  Melancholia. 

B.  Acute  mania. 

C.  Circular  insanity. 

4.  Functional  conditions. 

A.  Epilepsy. 

B.  Trigeminal  neuralgia. 

C.  Insomnia. 

D.  Neuropathic  individuals.     Hysteria. 

Literature. 

245 


CHAPTER  VIII 

BLOOD-PRESSURE  IN   NERVOUS  AND   MENTAL   DISEASES 

1.    DISEASES   OF   THE    SPINAL   CORD 

Very  little  study  has  been  made  of  the  arterial  tension  in 
cord  disease.  All  spastic  conditions  in  which  the  arms  are  in- 
volved are,  of  course,  excluded  from  observation  by  our  clinical 
methods,  on  account  of  the  influence  of  the  heightened  muscu- 
lar tone  on  the  transmission  of  the  pressure  (see  page  61).  In 
destructive  lesions  involving  the  higher  segments,  it  would  be 
of  interest  to  know  the  extent  to  which  the  vaso-motor  centres 
were  damaged,  so  far  as  one  might  judge  from  the  blood-pres- 
sure; but  I  know  of  no  measurements  under  such  conditions. 
Apart  from  this,  it  is  hard  to  see  what  special  significance  the 
arterial  pressure  could  have  in  this  group  of  disease,  except  for 
the  interesting  facts  which  have  come  out  in  connection  with 
locomotor  ataxia. 

A.  Tabes  Dorsalis. — Pal,  in  two  recent  articles,  has  thrown 
new  hght  on  vaso-motor  manifestations  in  connection  with  the 
lightning  pains  and  the  visceral  crises  of  tabetics.  He  exam- 
ined the  tension  during  the  attacks  by  Gartner's  tonometer, 
and  found  that  the  lightning  pains  were  attended  by  a  constant 
fall  in  pressure,  sometimes  of  considerable  extent.  In  certain 
severe  gastric  and  abdominal  crises,  however,  an  enormous  rise 
occurred,  up  to  150  per  cent,  of  the  original  pressure.  One 
woman  of  twenty-eight,  with  80  to  90  mm.  between  the  parox- 
ysms, had  170  to  190  mm.  in  moderate,  240  mm.  in  very  severe 
attacks.  A  thirty-year-old  man  had  65  mm.  pressure  when 
free  from  pain,  140  mm.  during  the  crisis.  The  climax  of 
hypertension  and  of  pain  seemed  to  coincide,  and  both  passed 
away  together.  Morphin  caused  sleep  and  a  lessening  of  the 
pain,  but  no  fall  in  pressure,  and  the  heart  often  showed  evi- 
dence of  weakness  after  its  use.     Chloral,  however,  exerted  a 

247 


248    BLOOD-PRESSURE   IN   NERVOUS   DISEASES 

hypotensive,  as  well  as  an  analgesic  effect.  Of  special  interest 
was  the  alternation  of  the  abdominal  and  the  lancinating  pains. 
Whenever  the  latter  came  on,  pressure  promptly  fell  and  the 
visceral  crisis  ceased. 

On  the  strength  of  these  findings  Pal  believes  himself  justi- 
fied in  assuming  that  a  spasm  of  the  splanchnic  vessels  is  the 
cause  of  the  suffering  in  a  gastric  crisis,  and  names  this  a 
vascular  crisis  (Gefasskrise).  On  the  other  hand,  the 
irritation  which  brings  on  the  lightning  pains  apparently  affects 
depressor  fibres  in  the  posterior  nerve  roots,  and  this  depressor 
stimulus  is  sufficient  to  interrupt  or  cut  short  an  abdominal 
vascular  crisis.  This  testimony  is  so  important  from  the  theo- 
retical, as  well  as  the  practical  therapeutic  standpoint,  that  it 
is  desirable  that  it  should  be  corroborated  or  qualified  by  subse- 
quent studies  as  speedily  as  possible. 

2.    DISEASES    OF   THE    BRAIN 

A.  Vascular  Diseases. — The  relation  of  cerebral  arterio-scle- 
rosis  to  general  arterial  disease  has  already  been  considered 
(see  page  189).  The  sphygmomanometer  gives  no  positive  evi- 
dence of  the  existence  of  changes  in  the  brain  vessels,  but  is  of 
distinct  service  where  these  are  suspected,  by  revealing  the 
presence  or  absence  of  essential  hypertension,  and  suggesting 
its  causative  factors  in  kidneys,  arteries,  or  heart.  When 
hypertension  is  marked,  cerebral  haemorrhage  becomes  more 
likely ;  when  absent,  thrombosis  is  the  greater  danger ;  so  that 
in  some  degree  both  prognosis  and  treatment  are  facilitated  by 
a  knowledge  of  the  arterial  pressure.  When,  on  the  other 
hand,  one  of  the  vascular  accidents  has  already  occurred,  the 
sphygmomanometer  helps  the  differential  diagnosis. 

a.  Cerebral  Haemorrhage. — Large  haemorrhages  into  the  cere- 
bral hemisphere  are  almost  always  attended  by  general  com- 
pression symptoms,  coma,  slow  pulse,  and  stertorous  or  Cheyne- 
Stokes  breathing.  Consequently  they  produce  marked  hyper- 
tension, which  is  more  extreme  the  greater  the  rise  in 
intracranial  tension.  The  reasons  for  this  have  already  been 
discussed  (see  page  140).  It  is  of  the  greatest  importance  to 
know  whether  a  comatose  patient  is  in  the  initial  or  advanced 
stage  of  manifest  cerebral  compression,  or  has  reached  the 


DISEASES   OF   THE   BRAIN  249 

period  of  terminal  paralysis.  No  single  bit  of  evidence  tells 
this  as  clearly  as  the  systolic  blood-pressure.  If  this  is  extreme, 
above  300  mm.  (5  cm.),  280  mm.  (12  cm.),  the  medulla  is  un- 
dergoing serious  compression,  and  danger  to  life  is  imminent. 
This  is  especially  true  if  marked  Traube-Hering  waves  can  be 
measured,  which  is  easily  done  by  maintaining  the  pressure  in 
the  sphygmomanometer  just  above  the  level  of  systolic  blood- 
pressure,  and  noting  whether  a  succession  of  large  pulse- waves 
come  through  periodically.  With  instruments  giving  diastolic 
pressure  it  is  even  simpler,  for,  with  the  pressure  held  at  the 
diastolic  level,  the  rhythmical  variation  in  size  of  the  pulse  is 
striking.  If,  however,  the  symptoms  are  not  urgent  and  the 
blood-pressure  is  not  high,  either  the  diagnosis  of  haemorrhage 
is  incorrect,  or  it  is  doing  local  rather  than  general  harm.  If 
the  patient  is  evidently  in  serious  condition,  with  deep  coma, 
Cheyne-Stokes  breathing,  or  cyanosis,  and  beginning  respiratory 
failure,  and  a  low  or  falling  blood-pressure  and  rapid  pulse  are 
found,  then  the  terminal  stage  has  set  in,  and  no  treatment  can 
much  retard  dissolution.  Nothing  could  be  more  valuable  in 
such  cases  than  a  blood-pressure  record  taken  at  frequent  inter- 
vals, as  Gushing,  and  Cook  and  Briggs  have  conclusively 
shown. 

A  high  and  rising  blood-pressure  indicates  progressive  fail- 
ure of  circulation  in  the  medulla  and  an  increasing  haemorrhage. 
On  account  of  the  circulus  vitiosus  established  under  such  con- 
ditions, this  rise  in  pressure  is  productive  of  more  rapid  bleed- 
ing ;  while  an  artificial  reduction  of  tension  by  drugs,  derivation, 
or  bleeding,  will  be  likely  to  kill  the  patient  by  the  cessation 
of  cerebral  circulation,  which  results  the  moment  the  general 
arterial  pressure  falls  below  the  intracranial.  In  consequence, 
some  surgeons,  especially  Gushing  in  this  country,  advocate 
immediate  operation,  as  for  extradural  haemorrhage,  with  relief 
of  intracranial  tension  and  evacuation  of  the  clot,  if  possible. 
In  cases  where  the  advance  of  the  compression  is  studied  by 
the  sphygmomanometer,  this  certainly  deserves  trial.  With  a 
stationary  or  falling  pressure,  without  increase  in  symptoms, 
it  should  not  be  thought  of  (see  Fig.  62). 

Haemorrhage  in  the  anterior  fossa  of  the  cranium  will  have 
the  least  ejffect  on  general  blood-pressure,  that  in  the  posterior 
fossa  most.     Hill  has  shown  how  great  pressure  discontinuity 


Fio.  62. 


Fig.  62. — Intracranial  hemorrhage  (apoplexy)  with  exploration  of  the  brain 
AND  evacuation  OF  A  LARGE  CLOT.     (Cook's  spliygm.  5  cm.) 

Persistent  extreme  hypertension  with  slow  (vajjus)  pulse,  resulting  from  mechanically 
increased  pressure  on  the  medulla. 

Exertion  (preparation  for  operation)  increasing  the  blood-pressure  by  exciting  further 
hffimorrhage,  and  so  increasing  intracranial  tension. 

Elevation  of  bone  flap,  and  brisk  external  haemorrhage,  reducing  the  blood-pressure 
momentarily. 

Immediate  complete  relief  of  the  hypertension  on  evacuation  of  the  compressing 
intracerebral  clot,  with  further  depression  due  to  slight  shock,  and  subsequent  return  of 
blood-pressure  to  the  normal  level  (arterio-sclerotic  patient).  (From  Cook  and  Briggs, 
Chart  No.  XIX.) 


252    BLOOD-PRESSURE   IN   NERVOUS   DISEASES 

exists  between  the  cerebral  and  cerebellar  chambers.  It  may 
be  hoped  that  the  sphygmomanometer  will  assist  in  the  diag- 
nosis of  the  rarer  cerebellar  haemorrhages,  which  are  sometimes 
puzzling.  The  most  conspicuous  posterior  fossa  haemorrhage, 
in  its  influence  on  the  medullary  centres,  is  that  accompanying 
fracture  of  the  base  of  the  skull.  Extreme  hypertension  is  a 
valuable  diagnostic  guide  in  this  injury,  sometimes  overlooked, 
which  occupies  the  border  line  between  neurology  and  surgery. 

Between  ursemic  and  apoplectic  coma  the  decision  is  more 
difficult,  for  a  marked  rise  in  pressure  attends  the  former. 
Figures  much  over  300  mm,  (R.  R.  5  cm.)  have  seldom  been 
reported,  however,  except  in  cerebral  compression.  A  recent 
case  of  acute  uraemia  at  City  Hospital,  in  which  no  significant 
brain  lesion  was  found  at  autopsy,  but  contracted  kidneys  with 
marked  fatty  change,  had  a  systolic  arterial  pressure  of 
290  mm.  (J.  12  cm.).  Further  data  are  necessary  before  defi- 
nite statements  can  be  made  on  this  question.  Here,  as  every- 
where in  medicine,  the  physician  who  gets  in  all  the  obtain- 
able facts,  including  the  blood-pressure,  will  less  frequently  go 
wrong  than  he  who  lays  undue  stress  on  any  single  diagnos- 
tic feature. 

b.  Cerebral  Thrombosis  and  Embolism. — Obstruction  of  a  brain 
artery  can  only  afi^ect  blood-pressure  directly,  when  the  circu- 
lation of  the  medulla  itself  is  suddenly  interfered  with.  Such 
a  lesion  would  be  rapidly  fatal.  Indirectly,  as  Hill  has  shown, 
it  may  produce  secondary  compression  through  surrounding 
congestive  or  inflammatory  oedema.  Practical  observations 
on  arterial  tension  under  such  conditions  are  lacking.  Moder- 
ate or  considerable  hypertension,  from  arterio-sclerosis  or  kid- 
ney disease,  is  not  uncommon  in  the  subjects  of  thrombotic 
hemiplegia  (see  Fig.  43),  but  I  have  never  seen  the  high  fig- 
ures reached  in  haemorrhage.  Unquestionably  the  finding  of 
approximately  normal  blood-pressure,  early  in  a  paralytic 
stroke,  makes  arterial  occlusion  highly  probable.  This  is  im- 
portant for  treatment.  If  haemorrhage  be  excluded  by  the 
mode  of  onset,  and  extent  of  the  local  manifestations  without 
general  compression  symptoms,  any  measures  which  lower 
general  blood-pressure  must  be  directly  injurious,  since  they 
diminish  the  speed  of  the  cerebral  circulation  and  favor  an 
extension  of  the  clot.     Far  more  are  stimulant  drugs,  such  as 


DISEASES   OF   THE   BRAIN  253 

caffein,  called  for;  and  the  effects  should  be  controlled  by  sys- 
tematic measurements  of  pressure. 

B.  Tumors  and  Inflammations. — Clinical  observations  of  blood- 
pressure  have  not  been  reported  in  connection  with  growths  or 
inflammatory  brain  lesions,  except  in  operations  for  their  re- 
moval. Hill  thinks  it  probable  that  tumors  cannot  of  them- 
selves cause  pressure  symptoms,  because  room  is  made  for 
their  slow  increase,  as  a  rule,  by  atrophy  of  brain  substance. 
Growths  of  the  posterior  fossa,  especially  when  they  obstruct 
the  veins  of  Galen  or  the  aqueduct  of  Sylvius,  cause  marked 
increase  of  intracranial  tension  and  must  be  associated  with 
high  blood-pressure.  The  same  should  be  true  where  consid- 
erable hsemorrhage  into  the  growth  takes  place,  or  when  there 
is  much  inflammatory  oedema  or  exudation  in  tumors,  men- 
ingitis, or  abscess.  Accurate  information  should  be  forth- 
coming. 

C.  General  Paresis. — Pilcz  has  examined  a  large  number  of 
patients  in  every  stage  of  general  paralysis.  He  found  normal 
tension  in  the  earlier  stages,  100  to  110  mm.  (G.),  falling  as  the 
disease  advanced.  In  the  terminal  bedridden  state  hypoten- 
sion became  extreme,  50  to  80  mm.  (G.).  This  seems  analo- 
gous to  the  subnormal  pressure  of  other  wasting  diseases,  but  is 
rather  more  pronounced.  In  several  patients  he  was  able  to 
foretell  death  by  the  rapid  fall  in  pressure.  Where  Bright's 
disease  was  present,  hypertension  was  in  evidence,  and  depres- 
sive mental  states  brought  about  a  rise.  The  remissions  in 
symptoms,  so  common  in  this  disease,  were  accompanied  by 
higher  tonometer  readings. 

The  only  other  report  on  general  paresis  is  from  Craig,  who 
himself  admits  that  his  cases  were  not  numerous  or  suitable 
enough  to  allow  of  conclusions. 

D.  Myasthenia  Gravis. — Stein ert  reports  a  case  of  myasthenia 
gravis,  in  which  the  systolic  pressure  was  low,  100  to  120  mm. 
(R.  R.  5  cm.).  The  patient  had  a  fall  in  pressure,  with  subse- 
quent rise,  in  a  cool  Nauheim  bath,  which  caused  a  well- 
marked  elevation  of  tension  in  a  healthy  man.  The  observa- 
tion is  a  purely  isolated  one.  It  is  quoted  here  because  the 
condition  is  described  in  neurological  text-books,  though  its 
real  pathology  is  not  yet  certain. 


254    BLOOD-PRESSURE   IN   NERVOUS   DISEASES 

3.    THE  PSYCHOSES 

Numerous  interesting  studies  on  blood-pressure  in  the  in- 
sane have  come  from  various  asyhims,  here  and  abroad.  The 
results  are  surprisingly  uniform. 

A.  Melancholia. — The  height  of  arterial  pressure  in  melan- 
cholia seems  to  bear  a_  definite  relation  to  the  intensity  of 
mental  suffering,  and  always  tends  to  be  above  the  normal 
average.  Cramer  gives  some  interesting  case  histories,  with 
charts,  which  show  this  connection  clearly  (see  Fig.  63).  His 
work  was  with  the  v.  Basch  sphygmomanometer,  but  Alex- 
ander,   and   Craig,    with   the  HiU  and   Barnard,    Pilcz,   and 


April 

9 

10 

11 

12 

13 

14 

15 

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ol 

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l(iO 

..g       150 

■§    ="     110 

W           100 

90 

\ 

\ 

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A 

V 

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A 

A 

V 

J 

\J 

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_ 

Very  aaxious 
jl    Anxious 

Free  from  anxiety 

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V. 

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-y 

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Fig.  CS. — Relation  between  p.Loon-FREssuRE  and  psychical  state  in  melancholia. 

(v.  Basch'8  spliygiii.) 

Chart  from  a  woman  of  forty,  witli  severe  mclaneliolia  of  one  year  and  one  quarter 
duration,  who  improved  during  the  period  represented,  becoming  paranoiac  later.  (From 
Cramer,  Curve  I.) 

Rosse,  with  the  tonometer,  and  Dunton,  with  the  Riva-Rocci, 
all  confirm  it.  Alexander  distinguishes  four  types  of  melan- 
cholia: simple  melancholia,  in  which  no  marked  elevation  of 
pressure  occurs;  an  acute  passive  type,  in  which  pressure  is 
invariably  high,  decreasing  as  the  symptoms  abate,  and  rising 
with  each  relapse;  an  acute  demonstrative  type,  with  more 
irregular  course,  not  so  marked  hypertension,  nor  so  constant 
a  descent  with  the  amelioration  of  symptoms;  lastly,  chronic 


THE   PSYCHOSES  255 

melancholia,  with  low  tension  except  during  acute  exacerba- 
tions of  the  mental  symptoms.  Craig  says  that  tension  is 
variable  in  agitated  melancholia,  corresponding  with  Alexan- 
der's demonstrative  cases.  Some  patients  in  stupor  he  found 
had  high  readings.  Pilcz  saw  readings  as  high  as  130  to 
300  mm.  (G.)  during  paroxysms  of  anguish.  As  regards  the 
causation  of  hypertension  during  intense  mental  depression,  it 
seems  reasonable  to  refer  it  to  abnormal  vaso-con'strictor  tone. 
Cramer  sees  in  the  high  pressure  the  source  of  the  acute  men- 
tal suffering — a  most  unlikely  theory,  since  hypertension  has 
no  such  sequence  in  its  most  marked  forms.  •  Alexander  be- 
lieves it  a  manifestation  of  toxaemia  from  retained  waste  prod- 
ucts. We  certainly  do  not  know  enough  of  the  morbid  physi- 
ology of  the  psychoses  to  hazard  an  explanation  of  this  rather 
constant  feature.  One  thing  it  seems  to  indicate  is,  that  acute 
melancholia  should  be  considered  an  active  mental  state. 
Craig  considers  the  sense  of  pressure  on  the  top  of  the  head, 
in  melancholies,  a  vascular  symptom.  So  far  as  treatment 
goes,  Craig  reports  improvement  in  some  patients  from  nitro- 
glycerin or  erythrol  tetranitrate.  He  also  noted  a  regular 
daily  fall  in  pressure,  with  abatement  of  the  anxiety,  toward 
evening. 

B.  Acute  Mania. — States  of  motor  excitement  have  the  op- 
posite effect  on  blood-pressure  from  conditions  of  mental  anxiety 
and  motor  depression.  In  mania  the  tension  is  regularly  low. 
Pilcz  found  that  persons  with  periodic  mania  had  25  to  30  mm. 
lower  pressure  during  the  excited  state.  In  the  exhaustion  fol- 
lowing a  maniacal  outbreak,  Craig,  and  Alexander  found  hypo- 
tension more  marked.  The  latter  did  not  see  subnormal  read- 
ings in  mania,  but  low  as  contrasted  with  melancholia.  Dunton 
thinks  in  either  case  the  motor  condition  has  greater  influence 
on  the  blood-pressure  than  the  mental. 

Baths  of  long  duration,  according  to  Posse,  are  followed  by 
a  rise  in  pressure  averaging  20  mm.  (G.),  and  exert  a  quieting 
effect  on  the  patient.  Craig  made  a  similar  observation  for 
baths  of  seven  to  eight  hours'  duration.  When  the  bath  was 
ineffective,  the  pressure  remained  unchanged. 

C.  Circular  Insanity. — In  circular  insanity  the  findings  for 
conditions  of  excitement  and  of  depression  hold  good  in  the 
main.     Pilcz  saw  a  few  exceptions  to  this  rule,  and  found  great 


256    BLOOD-PRESSURE   IN   NERVOUS   DISEASES 

variability  of  pressure  at  different  periods,  but  considers  the 
association  of  restlessness  with  low  pressure  usual.  He  thinks 
hypertension  a  factor  in  the  differential  diagnosis  of  stupor, 
occurring  with  it  in  circular  insanity,  but  being  absent  in 
catatonic  stupor. 

4.    FUNCTIONAL  CONDITIONS 

A.  Epilepsy. — In  epileptic,  as  in  other  convulsions,  a  marked 
rise  in  pressure  is  said  to  take  place.  One  can  scarcely  see  how 
accurate  readings  are  made  during  the  fit.  Pilcz,  in  two  cases, 
found  a  rapid  fall  as  soon  as  muscular  relaxation  set  it,  reach- 
ing normal  in  a  few  minutes.  Fere  found  much  the  same, 
though  not  so  prompt  a  subsidence.  His  figures,  using  Bloch's 
instrument,  are  of  little  worth.  The  condition  of  the  blood- 
pressure  after  a  convulsion  might  be  of  considerable  signifi- 
cance in  distinguishing  epilepsy  from  acute  uraemia,  in  which 
hypertension  persists  during  the  coma  and  is  a  permanent 
feature. 

B.  Trigeminal  Neuralgia. — Like  most  acute  pain  from  other 
causes,  the  paroxysms  of  this  agonizing  tic  cause  a  rise  in  blood- 
pressure.  The  height  reached  seems  fairly  proportional  to  the 
intensity  of  the  suffering.  There  is  no  coincident  change  in 
pulse-rate,  so  that  a  pure  reflex  vaso-constriction  seems  the 
probable  cause.  One  of  Cushing's  charts,  from  an  operation 
for  excision  of  the  Gasserian  ganglion,  shows  the  effect  of  two 
paroxysms,  before  the  administration  of  ether.  The  mild  one 
produced  a  rise  in  S3'stolic  pressure  from  100  mm.  to  190  mm., 
the  severe  one,  from  1G5  mm.  to  235  mm.  (R.  R.  5  cm,). 

C.  Insomnia. — Bruce  has  made  interesting  studies  of  blood- 
pressure  in  sleepless  patients,  on  the  basis  of  which  he  distin- 
guishes insomnia  with  high  blood-pressure,  130  to  150  mm. 
(H.  &  B.),  from  insomnia  with  normal  or  low  pressure.  The 
first  group  always  had  a  prompt  fall  in  pressure  when  they 
went  to  sleep.  Erythrol  tetranitrate,  in  these  patients,  acted 
as  a  hypnotic  if  it  reduced  tension.  This  makes  a  relation  be- 
tween the  hypertension  and  the  insomnia  manifest.  Paralde- 
hyde, in  dose  of  3ij,  was  the  most  certain  and  prompt  drug  in 
this  group,  sulphonal  and  trional  were  less  trustworthy,  and 
bromide  had  no  effect.  Sleep  was  possible  with  hypertension, 
but  always  produced  some  fall.     For  the  cases  with  normal 


FUNCTIONAL   CONDITIONS  357 

pressure,  sulphonal,  trional,  and  small  doses  of  paraldehyde 
were  most  efficient.  Kornfeld  made  comparative  measurements 
on  the  same  persons  in  natural  sleep  and  that  induced  by 
trional.  He  uniformly  observed  a  much  greater  fall  after  the 
drug,  in  some  cases  as  much  as  50  per  cent,  of  the  previous 
tension.  When  sleep  did  not  follow,  much  less  reduction  of 
pressure  occurred.  After  its  continued  use,  a  lowering  of  the 
average  daily  systolic  blood-pressure  was  noted.  Kornfeld 
thinks  the  hypotensive  effect  due  to  the  quieting  of  the  nervous 
system — that  is,  the  removal  of  reflex  vaso-constriction  from 
psychical  causes.  This  seems  reasonable.  It  suggests  the 
great  value  which  sleep  may  have  in  cardiac  cases,  reducing 
the  work  of  the  heart,  besides  permitting  repair  of  nervous 
tissues.  In  no  diseased  condition,  I  think,  is  the  beneficial 
effect  of  a  night's  rest  from  hypnotics  so  clearly  visible. 

D.  Neuropathic  Individuals.  Hysteria. — Heim  examined  25 
normal  and  68  neuropathic  children,  finding  considerably 
higher  tonometer  readings  in  the  latter,  1.30  to  150  mm.  He 
thinks  it  valuable  in  the  frequently  difficult  task  of  deciding  on 
the  reaHty  of  children's  complaints,  higher  pressure  indicating 
greater  psychical  irritability  and  suggesting  a  neurotic  basis. 
He  observed  no  difference  between  neurasthenia  and  hysteria. 

Rosse  found  that  hysterical  girls,  who  complained  of  pain 
and  other  abnormal  sensations  during  menstruation,  had  a 
steady  rise  of  20  mm.  during  the  flow,  instead  of  normal  or 
diminished  pressure.  Between  the  monthly  periods  the  pres- 
sure was  not  only  lower,  but  fluctuated  rapidly.  An  increase 
in  pulse-rate  attended  the  menstrual  rise  in  pressure.  Pilcz 
notes  a  cataleptic  boy,  bedridden  and  profoundly  emaciated, 
who  preserved  normal  blood-pressure.  I  have  seen  markedly 
neurasthenic  persons  with  rather  low  normal  systolic  pressure, 
and  diminished  pulse-pressure.  I  am  inclined  to  doubt  the  con- 
stancy of  high  tension  in  the  neurotic.  One  must  be  especially 
careful  not  to  confuse  the  neurasthenia  which  is  sometimes  due 
to  vascular  or  kidney  disease,  with  its  essential  hypertension, 
and  these  reported  high  normal  readings  in  simple  neuras- 
thenics. 


18 


258    BLOOD-PRESSURE   IN   NERVOUS   DISEASES 


LITERATURE 

Alexander,  H.  de  M.  A  Few  Observations  on  the  Blood-pressure  in  Men- 
tal Disease.     Lancet,  1902,  vol.  ii,  p.  18. 

Bruce,  L.  Some  Observations  upon  the  General  Blood-pressure  in  Sleep- 
lessness and  Sleep.  Scottish  Med.  and  Surg.  Jour.,  1900,  vol.  vii, 
p.  109. 

Cook,  H.  W.,  and  Briggs,  J.  B.  Clinical  Observations  on  Blood-pressure. 
Johns  Hojikins  Hosp.  Eep.,  1903,  vol.  xi,  p.  451. 

Craig,  M.     Blood-pressure  in  the  Insane.     Lancet,  1898,  vol.  i,  p.  1742. 

Cramer,  A.  Ueber  Verhalten  des  BlutdiiTcks  wahrend  der  Angst  der 
Melancholischen.     Miinch.  med.  Wochenschr.,  1892,  pp.  82  and  110. 

Gushing,  Harvey.  The  Blood-jiressure  Reaction  of  Acute  Cerebral  Com- 
pression, Illustrated  by  Cases  of  Intracranial  Haemorrhage.  Am.  Jour, 
of  the  Med.  Sci.,  1903,  vol.  cxxv,  p.  1017. 

On  the  Avoidance  of  Shock  in  Major  Amputations  by  Cocainization  of 

Large  Nerve-Trunks  Preliminary  to  their  Division.  "With  Observa- 
tions on  Blood-pressure  Changes  in  Surgical  Cases.  Ann.  of  Surgery, 
1902,  vol.  xxxvi,  p.  337,  Fig.  12. 

Dunton,  W.  E.,  Jr.  Some  Observations  upon  Blood-pressure  in  the 
Insane.     Boston  Med.  and  Surg.  Jour.,  1903,  vol.  cxlix,  p.  422. 

Fer6,  Ch.  La  pression  artgrielle  dansles  paroxysmes  epileptiques  et  dans 
le  colere.     Compt.  rend,  de  la  Soc.  de  Biol.,  1889,  vol.  i,  p.  368. 

Heim,  P.  Das  Verhalten  des  Blutdrucks  bei  neuropathischen  Kindern. 
Deutsch.  med.  "Wochenschr.,  1900,  vol.  xxvi,  p.  321. 

Hill,  Leonard.  The  Physiology  and  Pathology  of  the  Cerebral  Circula- 
tion.    London,  1896,  pp.  182-200. 

Kornfeld,  S.  Erfahrungen  iiber  Trional  als  Schlafmittel,  mit  besonderer 
Riicksicht  auf  die  Beeinfliissung  des  Blutdrucks.  Wien.  med.  Blatter, 
1898,  vol.  xxi,  pp.  3,  25  and  40. 

Pal,  J.  Ueber  Gefasskrisen  und  deren  Beziehung  zu  den  Magen  und 
Bauchkrisen  boi  Tabiker.  Miinch.  med.  "Wochenschr.,  1903,  vol.  L-, 
p.  2135. 

Die    vasomotorischen     Begleiter-scheinungen     der     lauzinierendeu 

Schmerzen  und  das  Alternieren  tabischer  Krisen.  Wien.  med. 
"Wochenschr.,  1904,  vol.  liv,  p.  2. 

Pilcz,  A.  Ueber  einige  Ergebnisse  von  Blutdruckmessungen  bei  Geistes- 
kranken.     "Wien.  klin.  "Wochenschr.,  1900,  vol.  xiii,  p.  276. 

Rosse.  Beitrag  zur  Blutdruckmessung  bei  Geisteskranken.  Allgem. 
Zeitschr.  f.  Psychiat.,  1903,  vol.  lix,  p.  737. 

Steinert,  H.  Ueber  Myasthenic  und  myasthenische  Reaktion.  Deutsch. 
Arch.  f.  klin.  Med.,  1903,  vol.  Ixxviii,  p.  346. 


CHAPTER  IX 

BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

1.  Uses  of  the  sphygmomanometer  in  surgical  practice. 

2.  Blood-pressure  during  surgical  operations. 

A.  Influence  of  the  ansesthetic. 

a.  Ether. 

b.  Chloroform. 

c.  Nitrous  oxide. 

d.  Cocain. 

B.  Influence  of  the  operative  procedures. 

a.  Peripheral  operations. 

b.  Operations  on  tlie  abdominal  cavity. 

c.  Gynaecological  operations. 

d.  Operations  on  the  thoracic  cavity. 

e.  Operations  on  the  cranial  and  vertebral  cavities. 

f.  Operations  on  the  genito-urinary  organs. 

3.  Blood-pressure  in  surgical  accidents  and  diseaseSo 

A.  Hsemorrhage. 
a.  Treatment. 

B.  Collapse  and  shock. 

a.  Prophylaxis. 

b.  Treatment. 

C.  Head  injuries. 

D.  Acute  peritonitis 

Literature. 

259 


CHAPTER  IX 

BLOOD-PRESSURE  IN   SURGICAL  CONDITIONS 

1.    USES  OF  THE  SPHYGMOMANOMETER   IN 
SURGICAL   PRACTICE 

The  evident  practical  value  of  blood-pressure  records  during 
operation,  and  in  the  study  of  certain  surgical  problems,  has 
been  so  ably  presented  by  Crile,  and  Gushing,  that  the  sphyg- 
momanometer is  finding  almost  as  wide  acceptance  among 
surgeons  as  among  medical  men.  The  illuminating  experi- 
ments of  Crile  (see  page  157)  upon  shock,  and  of  Cushing  on 
states  of  increased  intracranial  tension  (see  page  139),  make  its 
use  imperative  for  the  intelligent  treatment  of  these  two  con- 
ditions. As  a  guide  to  the  anaesthetist,  the  arterial  pressure 
seems  more  valuable  than  the  pulse  alone.  Both  together  are 
of  the  utmost  prognostic  significance.  Beyond  these  direct  re- 
sults, I  am  inclined  to  believe  that  pre-operative  observations 
of  blood-pressure  would  afford  indications  of  cardio-vascular 
disease,  in  some  patients,  which  might  well  influence  the  de- 
cision as  to  the  wisdom  of  operative  interference.  Such  a  use, 
I  fear,  might  not  be  a  universal  recommendation. 

2.    BLOOD-PRESSURE  DURING  SURGICAL 
OPERATIONS 

Systematic  measurement  of  the  blood-pressure  during  oper- 
ation is  being  widely  adopted  by  surgeons,  and  bids  fair  to  be- 
come general.  It  may  easily  be  carried  out  by  the  anaesthe- 
tist. To  be  of  value,  a  determination  should  be  made  every 
five  minutes,  and,  with  the  pulse-rate,  recorded  on  a  chart 
which  can  be  seen  by  the  operator.  This  procedure  was  orig- 
inally recommended  by  Cushing.  The  chart  described  hereto- 
fore is  well  adapted  for  this  purpose,  and  is  more  easily  read  if 
the  systoHc  pressure  be  marked  with  a  red  pencil,  the  pulse  in 

261 


2G2  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

blue  or  black.  The  condition  of  the  patient's  circulation  can 
then  be  taken  in  at  a  glance.  Systolic  pressure  alone  is  neces- 
sary, because  the  object  is  merely  to  follow  the  changes  in  ten- 
sion. It  can  be  measured  more  quickly  than  diastolic,  and  is 
more  affected  by  haemorrhage  and  other  causes  of  hypotension. 
In  order  to  utilize  such  a  graphic  record,  the  surgeon  must 
know  what  the  ordinary  influence  of  the  various  steps  in  a 
surgical  operation  are,  and  what  the  extraordinary  and  danger- 
ous manifestations.  These  will  be  taken  up  in  order,  so  far  as 
possible. 

A.  Influence  of  the  Anaesthetic,  a.  Ether. — All  observers 
agree  that  ether,  even  in  large  amounts,  seldom  produces  a 
significant  fall  in  blood-pressure.  This  agrees  with  the  evi- 
dence in  animals,  very  large  quantities  of  ether  being  required 
to  seriously  affect  heart  or  vaso-motor  system.  Duplay  and 
HalHon  have  recently  shown  this  anew,  and  called  attention  to 
the  blood-pressure  as  the  one  sure  danger  signal.  In  the  first 
and  second  stages  the  pressure  usually  rises,  due  to  the  excite- 
ment and  muscular  exertion,  but  in  full  surgical  ansesthesia  it 
falls  to  near  the  normal.  According  to  Cook  and  Briggs,  it 
never  produces  marked  hypotension  unless  causes  for  shock,  or 
cardiac  failure,  are  present.  As  the  patient  comes  out  of  narco- 
sis, the  pressure  curve  rises.  Blauel  tabulates  100  administra- 
tions, watched  with  the  tonometer.  In  79  per  cent,  there  was 
a  rise  in  pressure  during  the  whole  period;  in  9  per  cent,  no 
change  or  an  insignificant  fall.  Only  in  12  per  cent,  of  the 
cases  was  there  a  real  fall,  and  these  were  mainly  weak  per- 
sons, or  with  severe  haemorrhage  or  profuse  sweating  (see  Figs. 
64,  G7,  and  09). 

b.  Chloroform. — The  danger  of  sudden  death  during  chloro- 
form narcosis  has  always  been  emphasized  in  this  country, 
though  often  denied  abroad.  Blood-pressure  observations  cer- 
tainly put  the  fear  of  chloroform  on  a  sound  footing.  Except 
during  labor  (Cook  and  Briggs),  it  is  usually  attended  by  di- 
minished arterial  tension  from  the  start.  Duplay  and  Hallion, 
and  Remedi,  obtained  the  same  result  in  animals.  Blauel,  in 
39  cases,  found  a  marked  fall  in  09  per  cent.,  a  moderate  fall 
in  18.9  per  cent.  Only  10.8  per  cent,  showed  a  continued  rise 
in  pressure  throughout  narcosis,  and  8.1  per  cent,  an  average 
rise.     Kapsammer  gives  very  similar  figures  for  80  cases,  only 


BLOOD-PRESSURE  DURING   OPERATIONS     203 

5  showing  a  real  continued  rise.  The  diminution  in  tension 
was  usually  10  to  40  mm.  (G.) ;  a  few  times  GO  to  70  mm. ;  once 
120  mm.  PuriceUi  saw  some  increase  in  tension  during  the 
preparation  for  operation,  which  continued  during  the  first  stage 
of  anaesthesia,  after  which  it  regularly  decreased.     Neither  he 


Min.Hg. 
20 

15 

Ether                                                                                     Chloroform 

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Fig.  64. — Average  curves  of  blood-peessure  during  anesthesia. 
(Gartner's  tonometer  1.5  cm.) 

Left,  for  ether,  calculated  from  25,  and  right,  for  chloroform,  calculated  from  18  indi- 
vidual curves  of  healthy  persons  over  twenty  years  old,  during  narcosis  of  at  least  fifty 
minutes.  The  horizontal  N  signifies  the  normal  height  of  pressure.  (From  Blauel, 
Fig.  6.) 


nor  Kapsammer  could  discover  any  relation  between  the  previ- 
ous height  of  blood-pressure  and  the  tolerance  of  the  anaes- 
thetic. Awaking  from  anaesthesia,  coughing,  or  vomiting  in- 
creased the  pressure  by  20  to  30  mm.  Blauel's  chart  (Fig,  64), 
which  shows  an  average  curve  for  both  ether  and  chloroform, 
computed  from  a  number  of  cases,  is  more  instructive  than 
any  single  observation  (see  Fig.  70). 

c.  Nitrous  Oxide. — Laughing  gas,  as  one  might  expect, 
causes  some  hypertension,  from  the  partial  asphyxia  it  in- 
duces. According  to  Cook  and  Briggs,  when  given  with  ether 
it  eliminates  the  hypertension  of  the  second  stage  of  excite- 
ment, the  patient  passing  directly  from  the  primary  rise  to  the 
lower  pressures  of  deep  narcosis.  This  is  evident  in  several  of 
the  accompanying  charts  (see  Figs.  68  and  71). 

d.  Cocain. — Crile  reports  that  abdominal  operations  under 
local  anaesthesia  produce  less  depression  of  blood-pressure  than 


264  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

those  done  with  a  general  anaesthetic.  Of  course  protracted 
and  extensive  operations  were  impossible,  and  the  slight  effect 
on  blood-pressure  was  probably  due  in  large  part  to  the  small 
amount  of  manipulation  involved.  When  pain  or  fear  was 
produced,  tension  rose  irregularly,  with  subsequent  decline 
(see  Fig.  65).     Cook  and  Briggs  found  that  cocain,  adminis- 


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Fio.  65. — Thobacotomy  fob  post-pneumonio  empyema  under  local  cooain 
ANESTHESIA.     (Author's  sphygm.  12  em.) 

Note  the  great  rise  in  pressure  with  each  cutting  act,  especially  when  accompanied  by 
pain  (reflex  vaso-constriction). 

Operation  by  Dr.  Howard  Collins,  City  Ho.'^pital.    Observation  by  Dr.  A.  II.  Garvin. 


tered  hypodermically,  usually  produced  a  distinct  rise  in  pres- 
sure during  collapse  and  shock,  and  seemed  a  fairly  reliable 
vaso-motor  stimulant.  Infiltration  anaesthesia  must  also  in- 
crease blood-pressure  temporarily,  when  considerable  tension 
of  the  tissues  is  developed.  The  cocainization  of  large  nerve- 
trunks   will  be  considered   under  the   prophylaxis   of  shock. 


BLOOD-PRESSURE   DURING  OPERATIONS     2G5 

Cocainization  of  the  spinal  cord,  according  to  Gushing,  may- 
induce  dangerous  hypotension,  through  paralyzing,  in  the 
upper  dorsal  region,  the  efferent  nerve-fibres  which  control  the 
splanchnic  circulation.     Application  of  cocain  to  the  medulla 


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(Author's  sphygm.  12  cm.) 

Note  the  absence  of  any  special  change  in  pressure  during  the  operation,  after  the 
primary  rise,  due  to  the  pain  or  excitement. 

Operation  by  Dr.  Eugene  Fuller,  City  Hospital.  Observation  by  Drs.  A.  H.  Garvin 
and  Garside. 

oblongata,  in  Crile's  experiments,  reduced  the  blood-pressure 
to  40  or  50  mm.,  and  rendered  the  centre  inactive  to  reflex 
stimulation.  Apart  from  the  possible  direct  vaso-motor  paraly- 
sis, these  operations  show  little  pressure  variation  (see  Fig.  66). 
B.  Influence  of  the  Operative  Procedures,  a.  Peripheral  Opera- 
tions.— All  cutting  involves  the  irritation  of  peripheral  nerve- 
endings,  which,  as  a  rule,  provokes  reflex  vaso-constriction, 
just  as  in  the  laboratory  animal.     The  slight  rise  in  the  blood- 


2G6  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 


pressure  curve,  due  to  the  primary  incision,  is  visible  on  all 
charts  of  operations.  It  seldom  amounts  to  more  than  10  mm. 
In  shock  alone  this  pressor  effect  of  peripheral  irritations  is 
absent,  and  blood-pressure  is  unchanged,  or  shows  reflex  de- 


pression. 
t. 


Fio.  C7. — Forcible  strktohino  of  left  sciatic  nerve  for  sciatica. 
(Cook's  sphygm.  5  cm.) 

Primary  "ether  rise"  in  blood-pressure,  witli  slight  acceleration  of  the  pulse-rate. 

Marked  rise  in  blood-pressure,  with  greater  acceleration  of  tlie  pulse-rate,  during  the 
manipulation  of  the  nerve  (transient  pressor  eft'cct  of  peripheral  uervc  stimulation). 
(From  Cook  and  Briggs,  Chart  No.  11.) 

A  much  greater  reflex  rise  in  arterial  pressure  follows  the 
irritation  of  nerve-trunks.     This  is  typically  shown  in  Fig.  G7, 


BLOOD-PRESSURE   DURING   OPERATIONS     267 


from  stretching  of  the  sciatic  nerve.  It  is  a  chnical  diiphcate 
of  the  tracing  in  Fig.  5,  obtained  on  stimulation  of  the  anterior 
crural  nerve  in  a  dog.  A  similarly  marked  vaso-constriction 
follows  the  simple  operation  of  dilating  the  sphincter  ani. 
Gushing  suggests  that  the  sudden  deaths,  which  have  occa- 
sionally been  reported  during  these  slight  operations,  may  be 
due  to  rupture  of  a  diseased  cerebral  vessel  by  the  sudden 
hypertension. 


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FiG;  68. — Operation  for  osteomyelitis  of  femur.     (Author's  sphygm.  12  cm.) 

Note  the  primary  rise  in  blood-pressure  and  pulse-rate  from  nitrous  o.xide ;  the  absence 
of  any  further  rise  from  ether ;  the  fall,  as  full  ansesthesia  was  reached ;  the  incision  rise 
(15  mm.) ;  the  slight  subsequent  effect  of  the  operative  procedures. 

Operation  by  Dr.  Howard  Collins.     Observation  by  Dr.  Chapin. 

Severe  manipulation  of  large  mixed  or  sensory  nerves,  as 
in  forced  retraction,  the  separation  of  firmly  fixed  tumors, 
and  other  procedures  requiring  considerable  traction,  may 
cause  a  sharp  fall  in  blood-pressure.  In  Crile's  experience  this 
was  especially  pronounced  when  the  superior  laryngeal  nerve 


268  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

was  injured.  A  reflex  slowing  of  the  heart  coincided.  The 
same  effect  was  produced  by  irritation  of  the  laryngeal  mu- 
cous membrane  in  animals,  and  operations  on  the  larynx  are 
frequently  accompanied  by  dangerous  shock.  Kapsammer 
reports  a  fall  from  110  mm.  to  40  mm.  (G.),  with  profuse  sweat- 
ing, due  to  traction  on  the  sciatic  nerve  during  an  operation  for 
osteomyelitis  of  the  femur.  Section  of  large  nerve-trunks  also 
has  a  serious  depressor  effect,  and  may  lead  to  grave  hypoten- 
sion. Gushing,  and  Crile,  both  report  such  an  occurrence  in 
operations  involving  division  of  the  brachial  plexus. 


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BLOOD-PRESSURE  DURING   OPERATIONS     269 

little  faU  in  pressure  resulted  if  haemostasis  was  perfect ;  Crile 
found  that  rough  sponging,  blunt  dissection,  and  strong  re- 
traction caused  the  most  marked  depression.  These  clinical 
instances  of  reflex  vaso-dilatation  should  find  their  explana- 
tion in  the  knowledge  of  the  depressor  fibres  in  mixed  nerves 
(see  page  21),  which  is  as  yet  incomplete. 

b.  Operations  on  the  Abdominal  Cavity, — The  opening  of  the 
peritoneum  produces  a  much  sharper  rise  of  pressure  than 
skin  incision  (see  Fig.  69),  The  subsequent  course  of  the 
curve  is  downward,  in  extent  dependent  on  the  duration  of  the 
operation  and  the  amount  of  exposure  and  manipulation  of 
the  viscera.  Increased  pulse-rate  is  a  constant  accompani- 
ment. Simple  appendectomies,  and  other  procedures  in  which 
but  a  small  portion  of  intestine  is  handled,  according  to  Crile, 
show  little  change  in  pressure  after  the  first  fall.  The  more 
serious  and  protracted  operations,  however,  in  which  shock  is 
common,  need  constant  observation  of  the  tension.  Removal 
of  gangrenous  bowel,  in  strangulated  hernia  and  other  forms 
of  intestinal  obstruction,  sponging  the  intestine,  and  flushing 
the  abdomen,  all  lower  it.  The  upper  segment  of  abdomen 
seems  especially  sensitive  in  this  respect  (see  Fig.  70).  Crile 
was  unable  to  prove  any  effect  from  irritation  of  the  mucous 
membrane  of  the  intestine.  Every  irritation  of  the  peritoneum 
after  the  primary  incision,  however,  showed  on  the  blood-pres- 
sure chart. 

Cushing,  and  after  him  Cook  and  Briggs,  consider  the  fall 
in  pressure  during  laparotomies  as  due  to  direct  peripheral 
action  on  the  splanchnic  circulation.  This  may  be  true  in 
part.  Crile,  however,  noted  a  simultaneous  increase  in  respi- 
ration in  almost  every  instance.  This  could  only  have  been 
due  to  a  medullary  reflex,  and  makes  the  same  mechanism  a 
more  probable  explanation  of  the  hypotension. 

Simple  paracentesis  of  the  abdomen  causes  a  sHght  faU  in 
pressure,  due  to  release  of  the  intra-abdominal  tension.  Re- 
medi,  who  thinks  shock  is  due  principally  to  chloroform,  says 
that  laparotomies  on  dogs,  without  anaesthesia,  cause  only  a 
slight  lowering  of  mean  carotid  pressure,  2  to  8  mm, 

c.  Gynsecological  Operations. — Some  difference  of  opinion  ob- 
tains as  to  the  effect  of  operations  on  the  female  pelvic  organs. 
Crile,  in  almost  every  case,  found  the  manipulation  of  these 


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BLOOD-PRESSURE   DURING   OPERATIONS     271 

organs,  whether  from  their  vaginal  or  peritoneal  aspect,  pro- 
duced a  rise.  The  height  was  proportional  to  the  severity  of 
the  traumatism.  Schroeder,  on  the  other  hand,  thinks  these 
operations  show  a  considerable  lowering  of  pressure,  those  by 
the  vaginal  route  much  less  than  the  abdominal.  He  uses 
chloroform  narcosis,  but  thinks  the  laparotomy  much  more 
provocative  of  hypotension  than  the  ansesthetic.  Possibly  the 
combined  effect  explains  the  variation  of  his  results  from  Crile's. 
He  advocates  the  systematic  charting  of  blood-pressure,  during 
and  after  operations,  and  considers  a  secondary  fall,  after  the 
initial  recovery  of  pressure  succeeding  operation,  of  serious 
prognostic  significance.  Fig.  71  illustrates  an  abdominal  op- 
eration for  uterine  fibroids,  in  which  considerable  bleeding 
occurred. 

d.  Operations  on  the  Thoracic  Cavity.— Surgeons,  Hke  physi- 
cians, report  a  considerable  lowering  of  tension  on  the  removal 
of  pleural  exudates  (Crile,  Kapsammer).  This  shows  in  a 
small  way  in  Fig.  65.     Otherwise  I  know  of  no  observations. 

e.  Operations  on  the  Cranial  and  Vertebral  Cavities. — The  re- 
moval of  bone,  in  trepanation  or  laminectomy,  seems  to  exert 
httle  influence  on  blood-pressure.  Incision  of  the  dura  with  a 
sharp  knife  has  no  effect,  but  irritation  of  either  cerebral  or 
spinal  dura  mater  causes  a  fall  in  pressure,  most  marked  from 
sponging  (Crile).  The  influence  of  the  further  steps  depends 
on  the  underlying  lesion.  If  there  is  no  increased  intracranial 
tension,  incision  of  the  cortex,  or  probing,  are  unaccompanied 
by  marked  change.  If  cerebral  pressure  is  much  increased 
by  the  operation,  the  typical  blood-pressure  reaction  follows. 
Gushing  shows  this  especially  in  his  charts  from  operations  on 
the  Gasserian  ganglion.  Elevation  of  the  temporal  lobe,  to 
expose  the  ganglion,  produced  a  sharp  rise  in  the  curve.  He 
reports  one  case,  where  fatal  shock  followed  excision  of  the 
ganglion,  with  rapid  fall  in  pressure. 

When  operation  is  undertaken  for  the  relief  of  acute  cere- 
bral compression,  whether  from  middle  meningeal  or  intracere- 
bral haemorrhage,  or  fracture,  an  enormous  drop  in  arterial 
pressure  follows  the  release  of  the  intracranial  tension.  Fig. 
62,  taken  by  Briggs  from  one  of  Cushing's  cases,  is  typical  of 
this.  No  other  change  in  blood-pressure  met  with  clinically  is 
so  striking.     Hill,  Kocher,  and  Gushing  have  aU  called  atten- 


273  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

tion  to  the  necessity  for  extensive  osteoplastic  reaction  of  the 
skull  in  the'  treatment  of  general  cerebral  compression.  A 
small  opening  is  immediately  occluded  by  the  portion  of  cor- 
tex which  bulges  into  it,  and  no  good  is  done.  In  the  ter- 
minal stage  of  compression,  a  falling  blood-pressure  may  be 
arrested  by  immediate  operation,  even  when  artificial  respira- 
tion has  to  be  resorted  to  on  the  table,  as  Cushing  has  demon- 
strated. 

In  operations  for  tumor  of  the  brain,  Frazier  emphasizes 
the  importance  of  sphygmomanometric  observation.  He  reports 
instances  of  surgical  shock  with  typical  hypotension,  which 
developed  during  manipulation  of  the  brain  in  such  cases. 

f.  Operations  on  the  Genito-urinary  Organs. — Crile  observed  a 
fall  in  pressure  from  traction  on  the  spermatic  cord  during  her- 
niotomy and  operations  on  the  testicle.  Amputation  of  the 
penis  in  an  elderly  man  gave  a  distinct  fall.  The  removal  of 
a  large  carcinomatous  kidney  was  attended  by  marked  hj^po- 
tension.  During  all  procedures  in  this  field,  depressor  effects 
were  manifested,  if  the  blood-pressure  was  influenced  at  all. 
Fig.  72  shows  an  extreme  fall  in  pressure  during  prostatectomy, 
in  a  patient  with  chronic  interstitial  nephritis.  The  consider- 
able haemorrhage  acted  like  therapeutic  venesection  in  rehev- 
ing  hypertension. 

3.    BLOOD-PRESSURE    IN    SURGICAL  ACCIDENTS 
AND    DISEASES 

A.  Haemorrhage. — Loss  of  any  considerable  volume  of  blood, 
in  an  ansesthetized  patient,  results  in  an  immediate  descent  of 
the  blood-pressure  curve,  fairly  proportional  to  the  severity  of 
the  haemorrhage.  Unless  extreme,  or  succeeded  by  shock,  a 
compensatory  rise  follows.  The  predisposition  to  shock,  which 
accompanies  hypotension  from  acute  anaemia,  is  its  dangerous 
feature  in  most  cases.  Figs.  70,  71,  and  72  illustrate  the  effects 
of  bleeding  as  clearly  as  Fig.  0,  taken  in  the  laboratory. 

a.  Treatment. — The  study  of  therapeutic  measures  for  the 
relief  of  low  bl<jod-pressure  after  haemorrhage  must  never  neg- 
lect the  definite  physiological  tendency  of  the  blood-pressure  to 
return  unaided  to  its  normal  level.  No  interference  can  be 
accorded  any  value  unless  it  obviously  hastens  this  return. 
Saline  infusion,  either  intravenous  or  subcutaneous,  seems  to 


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SURGICAL   ACCIDENTS   AND   DISEASES       273 

accomplish  this,  experimentally  and  clinically,  by  mechanically 
increasing  the  blood- volume,  as  Fig.  70  demonstrates  strikingly. 
Crile,,  and  Cook  and  Briggs,  both  advocate  its  use.  In  hypo- 
dermoclysis,  peripheral  irritation  is  responsible  for  the  first  rise 
in  pressure.  Dawson  has  supplied  apparently  definite  evidence 
that,  in  animals  which  have  been  bled  severely,  a  solution  con- 
taining sodium  bicarbonate,  0.25  per  cent.,  in  addition  to  sodium 
chloride,  0.8  per  cent.,  is  more  efficacious  than  simple  saline. 
Unpubhshed  experiments  by  Stiles,  in  the  Physiological  Labo- 
ratory of  the  University  and  Bellevue  Hospital  Medical  Col- 
lege, proved  that  the  addition  of  calcium  salts  was  of  no  value 
whatever. 

In  hgemorrhage,  the  true  cardio-vascular  stimulants,  strych- 
nin, digitalin,  ergotin,  and  especially  adrenahn,  have  a  real 
influence,  as  Cook  and  Briggs's,  and  Crile's  work  shows.  In 
addition,  the  mechanical  measures  used  in  shock  are,  of  course, 
attended  by  benefit,  as  well  as  a  posture  which  saves  the  re- 
maining blood  for  the  brain. 

B.  Collapse  and  Shock. — The  early  recognition  and  treatment 
of  these  conditions  have  been  vastly  facilitated  by  the  introduc- 
tion of  the  sphygmomanometer  at  the  operating  table,  the  honor 
of  which  belongs  to  Cushing.  Cook  and  Briggs  feel  safe  in 
stating  that  a  fall  in  blood-pressure  is  their  surest  and  earhest 
manifestation,  and  affords  the  best  evidence  of  their  severity. 
Crile,  as  we  have  seen  (see  page  157),  applies  the  term  collapse 
to  the  more  sudden  falls  in  pressure,  shock  to  the  progTessive 
ones,  in  which  the  vaso-motor  centre  fails  to  respond  to  stimuli. 
The  mechanism  by  which  this  is  produced  is  through  repeated 
or  severe  traumatisms  to  sensory  nerves,  which  act  reflexly  on 
the  medullary  vaso-motor  centre.  Ordinary  injuries,  as  we 
have  seen,  cause  reflex  vaso-constriction.  When  the  vaso- 
motor centre,  however,  has  been  repeatedly  or  too  forcibly 
stimulated;  or,  as  Cushing  emphasizes,  it  has  been  affected  by 
certain  primary  or  secondary  ansemias,  as  in  profuse  haemor- 
rhage, it  responds  in  the  opposite  way.  The  peripheral  stimuli 
call  forth  a  fall  in  blood-pressure,  and  each  successive  operative 
manipulation  brings  the  curve  a  step  lower,  until,  in  profound 
shock,  it  passes  below  the  essential  limit  and  death  is  imminent. 
Shock,  of  course,  includes  the  depression  of  other  activities  of 
the  nervous  system,  but  the  important  point  is,  that  the  danger 
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Fig,  73. — Traumatic  shock  without  hemorrhage.     (Cook's  spLygm,  5  cm.) 

Very  low  blood-pressures  marking  the  depth  of  shock,  which  was  otherwise  clinically 
typical  and  marked. 

Temporary  rises  in  blood-pressure  after  each  of  two  smaller  doses  of  strychnin. 

Marked  depression  of  blood-pressure,  with  change  for  the  worse  in  every  symptom, 
during  the  continuance  of  an  infusion  of  normal  salt  solution  in  the  breast  (considerable 
local  tension). 

After  discontinuing  the  infusion,  steady,  progressive,  and  permanent  rise  in  blood- 
pressure  to  the  normal  level,  with  complete  recovery.  (From  Cook  and  Briggs,  Chart 
No,  VI.) 


276  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

to  life  lies  in  the  hypotension,  dependent  on  loss  of  central 
vaso-motor,  not  of  cardiac  function. 

Crile  found  that  he  could  produce  a  state  of  profound  shock 
as  surel}'  by  repeated  direct  stimulation  of  the  vaso-motor 
centre  with  str3'chnin,  as  he  could  by  reflex  stimulation  from 
peripheral  injury.  There  seems  no  question  of  the  facts  he  has 
adduced. 

a.  Prophylaxis. — This  includes  the  avoidance  of  all  those  un- 
necessarj^  injuries  to  peripheral  nerves  which  may  call  forth 
a  depressor  response ;  perfect  hsemostasis ;  and  the  minimum 
manipulation  of  abdominal  organs.  Rough  handling,  blunt 
dissection,  and  needless  expenditure  of  time,  are  dangerous, 
except  where  the  blood-pressure  shows  favorable  conditions. 
Chloroform  should  never  be  used  where  shock  is  feared.  Cush- 
ing,  and  Crile,  caU  attention  to  the  great  value  of  preventing 
the  abnormal  stimuli  from  reaching  the  medulla,  when  opera- 
tions necessarily  involve  injury  to  important  nerves.  This  is 
accomplished  by  the  injection  of  cocain  into  the  nerve-trunks 
before  their  division.  Thus,  in  major  amputations,  the  brachial 
plexus  may  apparently  be  divided  with  impunity  after  it  has 
been  "blocked"  by  cocain,  and  Crile  always  treats  the  superior 
laryngeal  nerve  in  the  same  way  in  neck  operations  of  any 
magnitude. 

b.  Treatment. — Whenever  the  blood-pressure  shows  serious 
depression,  chloroform  should  be  stopped  and  ether  substi- 
tuted. If  ether  is  being  used.  Cook  and  Briggs  believe  its  con- 
tinuance safer  than  to  allow  the  patient  to  come  out,  if  a  need 
for  the  renewal  of  the  anaesthetic  is  likely  to  arise.  AU  ma- 
nipulations, except  those  essential  to  completing  the  operation 
at  the  earliest  moment,  should  be  avoided. 

The  question  then  arises  as  to  the  means  of  combatting  the 
hypotension.  Here  the  entire  decision  hinges  upon  the  con- 
dition of  the  vaso-motor  centre.  Is  its  activity  absolutely  ex- 
hausted by  the  successive  stimuli  it  has  responded  to,  or  is  its 
function  merely  inhibited,  or  in  abeyance  ?  Crile  seems  to  have 
demonstrated  that,  in  profound  experimental  shock,  the  centre 
can  no  longer  respond  to  either  peripheral  or  central  stimula- 
tion. Since  he  could  produce  shock  equally  by  repeated  injec- 
tions of  strychnin,  he  seems  justified  in  assuming  that  to  use 
such  a  central  stimulant,  when  the  vaso-motor  centre  is  already 


SURGICAL   ACCIDENTS   AND   DISEASES        277 

exhausted  by  overstimulation,  is  positively  harmful.  On  the 
other  hand,  it  is  difficult  to  decide  clinically  whether  such  com- 
plete exhaustion  of  the  centre  exists  ;  and  Cook  and  Briggs 
have  shown  a  prompt,  and  apparently  life-saving  response  to 
strychnin  and  digitalin,  in  cHnically  profound  traumatic  and 
surgical  shock  in  Cushing's  wards.  This  has  followed  the  use 
of  large  doses,  up  to  gr.  -^  (see  Fig.  73). 

The  use  of  saline  infusion  in  shock  is  evidently  worthless, 
and  we  have  already  seen  that  alcohol  and  ether  are  not  hyper- 
tensive agents.  How  nitroglycerin  and  amyl  nitrite,  pure 
vaso-dilators,  could  be  given  by  any  intelligent  surgeon,  even 
before  Crile's  demonstration  of  their  futihty,  is  hard  to  under- 
stand. 

Adrenalin  seemed  to  offer  a  brilliant  prospect  of  control- 
ling blood-pressure  by  purely  peripheral  vaso-constriction.  Its 
effects  are  so  fugacious  (see  Figs.  57  and  58)  that  the  only  re- 
sults so  far  obtained  haVe  been  from  using  it  continuously,  by 
intravenous  infusion  in  saline  solution,  1  in  50,000  or  100,000, 
with  addition  of  atropin,  after  Crile's  method.  Some  sudden 
deaths  have  followed  this,  and  Cook  and  Briggs  have  found 
that  the  general  symptoms  did  not  improve  with  the  blood- 
pressure.  The  most  rational  method  of  maintaining  the  blood- 
pressure  for  long  periods  of  time,  and  at  any  desired  level, 
seems  to  be  Crile's  pneumatic  suit.  Some  wonderful  results 
have  been  obtained  with  it,  and  the  greatest  credit  is  due  him 
for  its  invention.  It  deserves  extensive  trial,  and  warrants 
considerable  hope. 

c.  Head  Injuries. — It  is  impossible  to  enter  into  the  compli- 
cated questions  involved  in  the  differential  diagnosis  of  concus- 
sion, contusion,  and  compression  of  the  brain,  which  are  so 
admirably  presented  in  Kocher's  monograph.  Measurement  of 
the  blood-pressure  is  of  considerable  service  in  connection  with 
all  other  general  and  focal  symptoms.  A  low  blood-pressure 
may  be  present  in  concussion,  as  are  certain  other  symptoms  of 
shock;  in  direct  injury  to  the  medulla;  and  in  compression, 
during  the  terminal  stage.  "When  found  early  after  injury,  it 
is  an  indication  for  artificial  respiration  and  transfusion,  ac- 
cording to  Kocher,  to  increase  the  arterial  blood-supply  of  the 
meduUa.  It  is  not  so  immediately  dangerous  as  respiratory 
arrest.     With  hypotension,  operation  is  not  indicated  for  the 


278  BLOOD-PRESSURE  IN  SURGICAL  CONDITIONS 

relief  of  general  cerebral  symptoms,  unless  it  be  undertaken  as 
a  forlorn  hope,  in  the  paralytic  stage  of  compression. 

Hypertension  is,  as  we  have  seen,  direct  evidence  of  anae- 
mia of  the  medulla  from  compression  (see  page  141).  "When  it 
supervenes  after  injury,  it  seems  one  of  the  best  indications  for 
operative  interference.  Cushing,  in  this  country,  has  studied 
the  matter  especially,  and  advocates  surgical  interference  in 
non-traumatic  cases  of  general  cerebral  compression  as  well. 
There  seems  no  reason  why,  with  the  blood-pressure  mount- 
ing above  300  mm,,  an  intracerebral  clot  should  not  be  evacu- 
ated, as  much  as  one  from  the  middle  meningeal  artery.  So 
far  as  traumatic  cases  are  concerned,  Kocher  regards  the  ap- 
pearance of  the  slow  high  tension  pulse,  and  other  symptoms 
of  advanced  compression,  as  evidence  that  the  favorable  period 
for  surgical  intervention  has  passed.  The  earlier  diagnosis 
must  depend  on  focal  manifestations  of  local  pressure,  which 
have  not  yet  appreciably  raised  the  tension  in  the  posterior 
fossa. 

Every  case  of  head  injury,  or  cerebral  accident,  should  by 
all  means  have  systematic  blood-pressure  measurements  taken 
at  short  intervals.  The  effects  of  operation  are  most  strikingly 
exhibited  on  the  blood-pressure  chart  (see  Fig.  62). 

d.  Acute  Peritonitis. — Crile  studied  the  arterial  tension  in 
twenty  cases  of  acute  peritonitis  from  various  causes,  and 
found  a  moderate  hypertension  in  all,  probably  dependent  on 
reflex  vaso-constriction  from  the  peritoneal  irritation.  His 
highest  reading  was  208  mm.,  lowest  156  mm.,  and  average 
166  mm.  (R.  R.  5  cm.).  This  may  be  of  some  diagnostic  value, 
especially  in  the  recognition  of  perforative  peritonitis  in  ty- 
phoid, which  has  already  been  considered.  Late  in  the  course, 
as  collapse  develops,  the  blood-pressure  sinks.  Heineke  de- 
monstrated this  in  animals  (see  page  156),  the  cause  being 
vaso-motor  paralysis  similar  to  that  in  other  infections. 

LITERATURE 

Blauel,  C.  Das  Verhalten  des  Blutdrucks  boiin  Menschen  wiihrend  der 
Aether- und  der  Chloroform-Narkose.  Beitr.  z.  klin.  Chirurg.,  1901, 
vol.  xxxi,  p.  271. 

Cook,  H.  W.,  and  Briggs,  J.  B.  Clinical  Observations  on  Blood-pressure. 
Johns  Hopkins  Hosp.  Rep.,  1903,  vol.  xi,  p.  451. 


LITERATURE  279 

Crile,  Geo.  W.     Blood-pressure  iu  Surgery.     Philadelphia,  1903. 

Diagnostic  Value  of  Blood-pres.sure  Dotermiuatious  in  the  Diagnosis 

of  Typhoid  Perforations.     Jour,  of  the  Am.  Med.  Ass'n,  1903,  vol.  xl, 

p.  1292. 
Gushing,  Harvey.     On  the  Avoidance  of  Shock  in  Major  Amputations  by 

Oocainization  of  Large  Nerve-trunks  Preliminary  to  their  Division. 

"With   Observations   on    Blood-pressure   Changes  in  Surgical  Cases. 

Ann.  of  Surgery,  1902,  vol.  xxxvi,  p.  321. 
Some  Experimental  and  Clinical  Observations  concerning  States  of 

Increased  Intracranial  Tension.     Am.  Jour,  of  the  Med.  Sci.,   1902, 

vol.  cxxiv,  X).  375. 
The  Blood-pressure  Reaction  of  Acute  Cerebral  Compression,  Illus- 
trated by  Cases  of  Intracranial  Haemorrhage.     Am.  Jour,  of  the  Med. 

Sci.,  1903,  vol.  cxxv,  p.  1017. 
Dawson,  Percy  M.     Efifect  of  Intravenous  Infusion  of  Sodium  Bicarbo- 
nate after  Severe  Haemorrhage.     Am.  Jour,  of  Physiol.,  1904,  vol.  x, 

Proceed,  of  Am.  Physiol.  Soc,  jd.  xxxvi. 
Duplay,  S.,  et  Hallion,  L.      Recherches  sur  la  pression  arterielle  dans 

I'ansesthesie  par  le  chloroforme  et  jDar  I'ether.     Arch.  gen.  de  Med., 

1900,  vol.  ix,  p.  130. 
Frazier,  C.  H.     A  Discussion  of  the  Surgery  of  Tumors  of  the  Brain. 

Am.  Jour,  of  the  Med.  Sci.,  1904,  vol.  cxxvii,  -p.  316. 
Kai^sammer,   Geo.     Blutdruckmessungen  mit  dem  Giirtner'scheu  Tono- 
meter.    Wien.  klin.  Wochenschr.,  1899,  vol.  xii,  p.  1279. 
Kocher,  Th.     Hirnerschiitterung,   Hirndruck  und  chirurgische  Eingriffe 

bei  Hirnkrankheiten.     Nothnagel's  spec.  Pathol,  u.  Therap. ,  vol.  ix. 

IIITh.,  II  Abth.,  Vienna,  1901. 
Puricelli.     La  pressione  sanguine  in  rapporto  agii  accidenti  della  narcosi 

chloroformica.      Centralbl.  f.  Chirurg. ,  1900,  vol.  xxvii,  p.  1318. 
Remedi.     Modificazioni  della  pressione  sanguine  nella  operazione  die  si 

practicano  nelle  cavita.     Centralbl.  f.  Chirurg.,  1900,  vol.  xxvii,  p.  93. 
Schroeder,  H.     Untersuchungen  iiber  den  Blutdruck  von  und  nacli  Opera- 

tionen.     Miinch.  med.  Wochenschr.,  1900,  vol.  xlvii,  p.  1437. 
Ueber  Blutdruckschwankungen  nach  gynakologischen  Operationen. 

Centralbl.  f.  GynakoL,  1900,  vol.  xxiv,  p.  1045. 


CHAPTER  X 

BLOOD-PRESSURE  IN  OBSTETRICAL  CONDITIONS 

1.  Value  of  the  sphygmomaiioineter  in  obstetrical  practice. 

2.  Blood-pressure  during  pregnancy. 

3.  Blood-pressure  during  labor  and  the  puerperium. 

A.  Labor. 

a.  Influence  of  chloroform, 

b.  Influence  of  obstetrical  operations. 

c.  Influence  of  hfemorrhage  and  exhaustion. 

B.  The  puerperium. 

4.  Puerperal  eclampsia. 

Literature. 

281 


CHAPTER  X 

BLOOD-PRESSURE  IN  OBSTETRICAL   CONDITIONS 

1.   VALUE  OF  THE  SPHYGMOMANOMETER  IN 
OBSTETRICAL  PRACTICE 

Comparatively  Kttle  use  has  yet  been  made  of  the  sphyg- 
momanometer by  obstetricians.  During  labor,  the  accoucheur 
is  quite  enough  occupied  without  making  blood-pressure  ob- 
servations. Nevertheless,  one  or  two  measurements  before  and 
after  labor  would  be  a  small  price  to  pay  for  the  information 
concerning  certain  of  the  most  dreaded  obstetrical  accidents, 
which  can  be  obtained  in  this  way.  As  I  have  said  before,  an 
intelligent  nurse  may  easily  be  taught  to  make  observations  of 
sufficient  accuracy  for  clinical  purposes,  and  could  keep  the 
physician  informed  of  the  movements  of  blood-pressure,  in 
cases  where  mishaps  are  feared. 

The  greatest  importance  attaches  to  the  arterial  pressure  as 
a  means  of  foretelhng,  and  in  consequence  perhaps  forestalling, 
an  eclamptic  seizure.  As  a  measure  of  shock,  which  may 
accompany  obstetrical  operations,  and  of  the  dangerous  results 
of  haemorrhage,  it  has  the  same  value  as  in  surgical  cases. 
Besides  these  more  conspicuous  uses,  I  believe  that  blood- 
pressure  determinations  should  be  made  during  pregnancy 
whenever  the  urine  is  examined,  and  for  the  same  reason.  As 
a  guide  to  the  seriousness  of  a  pregnancy  nephritis  and  its 
liabihty  to  terminate  in  eclamptic  convulsions,  such  a  record 
would  be  far  more  adequate  than  the  usual  urinary  report. 

The  literature  contains  but  scanty  references  to  studies 
along  these  lines,  and  few  of  those  are  with  accurate  instru- 
ments. Cook  and  Briggs's  cases,  so  admirably  shown  in  their 
charts,  should  stimulate  investigation  in  lying-in  hospitals. 
The  systematic  recording  of  blood-pressure  in  large  series  of 
cases  ought  to  demonstrate  its  very  practical  usefulness. 

283 


284  BLOOD-PRESSURE   IN   OBSTETRICS 

2.    BLOOD-PRESSURE   DURING   PREGNANCY 

Before  definite  statements  can  be  made  concerning  the  in- 
fluence of  pregnancy  on  blood-pressure,  there  must  be  accurate 
records  on  the  same  women,  at  moderate  intervals,  throughout 
its  whole  duration.  These  are  impossible  in  hospitals,  where 
the  waiting  women  come  late,  and  must  be  furnished  from 
private  practice.  At  present,  only  measurements  on  different 
cases  at  different  periods  exist.  Hence  we  find  Queirel  and 
Reynaud  claiming  that  hypertension  exists  throughout,  in- 
creasing up  to  labor;  Wiessner,  that  a  rise  occurs  during  the 
later  months ;  while  Vaquez  and  Millet,  Goldwater,  and  Cook 
and  Briggs  never  found  readings  above  the  normal  limit  until 
uterine  contractions  had  actually  begun.  The  latter  authors 
made  the  interesting  observation  of  a  fall  in  pressure  with  the 
descent  of  the  foetal  head  into  the  pelvis,  in  the  ninth  month. 
This  seems  good  evidence  of  some  previous  increase  in  tension 
above  the  normal  for  the  individual,  from  the  augmented  intra- 
abdominal pressure  (see  page  15).  They  also  noted  a  rise  in 
systolic  pressure  accompanying  the  painless  uterine  contrac- 
tions during  pregnancy. 

The  whole  question  is  one  it  would  be  worth  while  to  solve. 
The  studies  of  Dreysel,  who  made  weighings  of  the  heart  by 
Miiller's  method,  in  autopsies  of  seventy-six  pregnant  women, 
showed  a  distinct  hypertrophy  of  both  ventricles,  which  was 
proportional  to  the  increase  in  body- weight.  The  existence  of 
such  an  absolute,  but  not  relative  hypertrophy,  would  be  no 
reason  for  assuming  that  hypertension  would  coexist,  as  we 
have  already  seen  in  discussing  the  hypertension  of  chronic 
nephritis  (see  page  140).  Fiith  and  Kronig  were  unable  to 
prove  increased  viscosity  of  the  blood  in  pregnant  women. 
The  considerable  intra-abdominal  tension  during  the  last 
months  seems  to  me  an  adequate  cause  for  what  Httle  eleva- 
tion of  pressure  may  occur. 

The  most  important  point,  at  least,  is  settled.  Real  absolute 
hjT)ertension,  say  above  180  mm.  (5  cm.),  160  mm.  (12  cm.), 
does  not  exist  during  normal  pregnancy.  The  discovery  of 
such  tension,  especially  on  several  examinations,  should  be  re- 
garded as  distinct  evidence  of  mischief,  and  the  kidneys  care- 
fully watched. 


BLOOD-PRESSURE  DURING   LABOR  285 

3.    BLOOD-PRESSURE   DURING   LABOR  AND  THE 
PUERPERIUM 

A.  Labor.— Several  factors  coincide  to  raise  the  arterial  pres- 
sure during  labor.  The  excitement,  the  muscular  effort,  the 
contraction  of  the  abdominal  walls,  the  painful  sensory  impulses, 
all  assist.  Nevertheless,  Cook  and  Briggs  have  shown  that 
there  is  a  constant  rise  in  pressure  during  each  pain,  exactly 
parallel  with  the  uterine  contraction,  and  that  this  elevation  is 
almost  as  great  under  full  chloroform  narcosis.  A  chart  dur- 
ing labor  shows  these  regularly  recurring  peaks  on  the  pressure 
curve,  which  are  much  more  striking  than  the  sHghter  accelera- 
tion of  the  pulse.  Whether  due  to  the  emptying  of  the  uterine 
sinuses,  and  consequent  increased  blood-supply  to  the  heart,  or 
to  reflex  vaso-constriction,  or  both,  does  not  appear.  Between 
the  pains,  tension  remains  at  a  higher  level  than  before  the 
onset  of  labor.  As  the  pains  become  more  frequent  and  severe, 
both  the  average  level  and  the  maximum  elevation  go  higher, 
until  the  child  is  expelled,  when  there  is  an  immediate  fall  to 
somewhat  below  normal  for  the  individual.  Wiessner  has  seen 
a  drop  of  100  mm.  (R.  R.  5  cm.)  after  the  birth.  Vaquez  and 
Millet,  and  Queirel  and  Reynaud  give  a  similar  picture,  which 
seems  well  substantiated.  Only  Lebedoff  and  Porochjakow 
failed  to  find  pressure  so  high  during  labor  (v.  Basch  sphygm.). 
One  great  source  of  error  exists  for  observations  under  these 
conditions.  The  voluntary  contractions  are  not  localized  to  the 
abdomen,  and  even  the  arms  may  participate.  Even  a  slight 
heightening  of  muscular  tone  in  the  arm  would  give  a  fictitious 
value  for  the  blood-pressure  and  must  be  avoided.  Cook  and 
Briggs's  findings  under  chloroform,  however,  make  it  evident 
that  the  hypertension  is  real. 

a.  Influence  of  Chloroform. — The  fact  is  well  known,  that  ac- 
cidents during  the  administration  of  chloroform  are  most  ex- 
ceptional in  obstetrical  practice,  as  compared  with  surgical 
anaesthesia.  Cook  and  Briggs  suggest  that  this  may  be  due 
to  the  fact  that  hypertension  during  labor  is  the  rule.  Not 
only  labor  itself,  but  operative  interference  to  hasten  it,  have 
marked  pressor  effects,  which  would  certainly  tend  to  counter- 
act the  effect  of  the  chloroform.  Some  faU  in  pressure  attends 
its  use  here,  as  in  surgery,  but  never  to  a  dangerous  level. 


286 


BLOOD-PRESSURE  IN  OBSTETRICS 


Queirel  and  Reynaiid  report  the  lowest  figures  during  labor  as 
occurring  during  its  administration. 

b.  Influence  of  Obstetrical  Operations. — Instrumental  delivery, 
version,  and  other  methods  of  forced  delivery  seem  to  cause  a 
sharp  elevation  of  blood-pressure.  According  to  Cook  and 
Briggs,  this  "pelvic  reflex"  rise  occurs  on  the  introduction  of 
the  whole  hand  into  the  vagina,  but  is  most  extreme  when 
strong  traction  is  exerted  on  the  child.  Such  hypertension 
makes  intelligible  the  occasional  rupture  of  a  cerebral  vessel 
which  has  occurred  under  these  circumstances. 


Fig.  74. — Post-operativk  depression.    (Cook's  sphygm.  5  cm.) 

Comhined  sliock  and  hajinorrhage  in  twin  labor,  after  prolonged  forcible  attempts  at 
instrumental  delivery. 

Stryclinin  in  lartrc  amounts  producinfr  immediate  and  permanent  rise  in  blood-pres- 
sure.    (From  ('ooU  and  Brigfr.s,  Chart  No.  VII.) 


c.   Influence  of  Haemorrhage  and  Exhaustion. — Both   loss  of 
blood  and  unusual  exhaustion,  which  may  even  constitute  real 


PUERPERAL   ECLAMPSIA  287 

collapse,  produce  hypotension.  The  extent  of  the  fall  in  pres- 
sure, and  the  level  at  which  it  is  maintained,  are  proportional 
to  the  danger  that  exists.  Fig.  74,  from  Cook  and  Briggs, 
shows  such  a  condition  of  hypotension  and  its  prompt  disap- 
pearance after  a  large  hypodermic  of  strychnin.  The  blood- 
pressure  curve  here,  as  in  other  conditions  of  vaso-motor  de- 
pression, is  probably  one  of  the  best  indications  of  the  neces- 
sity for  stimulation,  and  of  its  effect. 

B.  The  Puerperimn. — The  changes  in  blood-pressure  after 
the  birth  of  the  child  must  be  of  small  consequence,  and  de- 
pendent on  more  or  less  individual  causes.  Thus  Wiessner 
found  readings  lower  than  in  pregnancy  (R.  R.);  Goldwater, 
a  very  shght  diminution  in  tension  during  the  first  three  days, 
7  mm.  (G.)  at  the  greatest;  Lebedoff  and  Porochjakow,  a  fall 
of  at  least  18  mm.  (v.  B.)  during  the  early  days,  with  a  return 
to  normal  during  the  second  week;  while  Queirel  and  Rey- 
naud  report  a  rise  in  pressure,  attaining  its  maximum  as  a 
rule  on  the  fourth  day,  with  subsequent  slow  decline. 

These  latter  observers  noted  a  rapid  development  of  hyper- 
tension with  any  complicating  inflammatory  disease;  perito- 
nitis, pneumonia,  or  grippe.  The  Verdin  sphygmomanometer, 
which  they  used,  casts  suspicion  on  all  their  results. 

4.    PUERPERAL  ECLAMPSIA 

There  is  no  difference  of  opinion  as  to  the  value  of  the 
sphygmomanometer  in  the  detection  and  treatment  of  eclamp- 
sia. Hypertension  has  been  invariable  in  all  the  cases  so  far 
observed,  as  in  acute  uraemia.  The  existence  of  high  pressure 
during  pregnancy  is  a  warning  of  its  possible  occurrence, 
which  seems  of  more  value  than  the  finding  of  albuminuria. 
I  am  unable  to  speak  from  personal  experience,  but  the  testi- 
mony is  so  convincing  and  harmonizes  so  perfectly  with  what 
we  know  of  blood-pressure  before  ursemic  convulsions,  that  I 
feel  assured  of  the  wisdom  of  sphygmomanometric  measure- 
ments as  a  routine  during  pregnancy. 

During  labor  itself  the  hypertension  is  harder  of  recogni- 
tion, because  in  large  degree  a  normal  feature.  After  dehv- 
ery,  however,  if  the  pressure  does  not  fall,  eclampsia  must  be 
considered  immanent.  In  all  the  cases  studied  by  Cook  and 
Briggs,  this  post-partum  hypertension  was  invariably  followed 


288 


BLOOD-PRESSURE   IN   OBSTETRICS 


by  convulsions  sooner  or  later.  Wiessner,  Fiith  and  Kronig, 
and  Vaquez  and  Nobecourt,  all  insist  on  the  great  importance 
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Fig.  75.— Puerperal  eclampsia.    (Cook's  sphygm.  5  cm.) 

Hypertension  durinK  luhor. 

No  relief  of  tlie  abiioriually  liitfli  blood-pressure  foUowinj,'  delivery,  only  a  very  tem- 
porary fall  occurring. 

With  the  persistence  of  hypertension,  development  of  eclamptic  symptoms  and  con- 
vulsions seven  and  a  half  hours  post  partuin. 

With  the  relief  of  liypertcusimi  (hy  the  usual  methods)  disappearance  of  tlie  eclamp- 
tic features.     (From  Cook  and  Urij^fjs,  Chart  No.  XV.) 

During  the  actual  seizure  the  tension  reaches  very  high 
figures,  Wiessner  having  seen  it  280  mm.  (R.  R.  5  cm.).  With 
its  reduction  by  the  vaso-dilators  or  chloroform,  the  convul- 
sions disappear.     Wiessner  was  unable  to  diminish  the  pres- 


PUERPERAL   ECLAMPSIA  289 

sure  by  venesection  and  the  abstraction  of  200  to  300  c.c.  of 
blood.  Pal  endeavors  to  bring  eclamptic  amaurosis  into  line 
with  the  similar  transient  blindness  in  ursemia  and  lead  poison- 
ing, as  due  to  circulatory  disturbance  in  the  occipital  lobe, 
dependent  on  the  hypertension.  He  quotes  no  personal  ob- 
servation. 

It  is  sincerely  to  be  hoped  that  obstetricians  in  general  will 
recognize  the  help  which  the  sphygmomanometer  can  gi  e 
them  in  this  condition.  To  take  the  arterial  tension  is  far 
easier  than  examining  the  urine,  and  the  information  thus  ob- 
tained is  no  whit  less  valuable.  A  few  measurements  by  the 
nurse,  during  and  after  labor,  would  give  a  most  welcome 
confidence  that  danger  from  this  particular  quarter  was  un- 
likely. 

LITERATURE 

Cook,  H.  W. ,  and  Briggs,  J.  B.  Clinical  Observations  on  Blood-pres- 
sure.    Johns  Hopkins  Hosp.  Rep.,  1903,  vol.  xi,  p.  451. 

Dreysel,  Max.  Ueber  Herzliypertrophie  bei  Sclivpangeren  und  Woclmer- 
innen.  Inaug.  Dissert.,  Miinchen,  1891.  Quoted  by  Dienst.  Arch, 
f.  Gynakol.,  1902,  vol.  Ixv,  p.  367. 

Filth  und  Kronig.  Experimentelle  Untersuchungen  zur  Xtiologie  der 
Eklampsie.     Centralbl.  f.  Gynakol.,  1901,  vol.  xxv,  p.  701. 

Goldwatei-,  S.  S.  Notes  on  Blood-pressure  in  Man,  Med.  News,  1903, 
vol.  Ixxxii,  p.  926. 

Lebedoflf,  A.,  und  Porochjakow.  Basch's  Sphygmomanometer  und  der 
Blutdruck  wahrend  der  Geburt  und  des  Wochenbettes  in  Zusam- 
menhange  mit  Puis,  Temperatur  und  Respiration.  Centralbl.  f. 
Gynakol.,  1884,  vol.  viii,  p.  1. 

Pal,  J.  Zur  Pathogenese  der  akuten  transitorischen  Amaurose  bei  Blei- 
kolik,  Uramie  und  Eklampsie.  Centralbl.  f.  in.  Med.,  1903,  vol.  xxiv, 
p.  417. 

Queirel  et  Raynaud.  Tension  art6rielle  et  puerperalit6 — grossesse — ac- 
couchement— suites  de  couches — i^hysiologiques  et  patliologiques. 
XTII  Congrfes  internat.  de  med.,  Paris,  1900,  vol.  xv,  Sect,  d'obste- 
trique,  p.  170. 

Vaquet,  H.,  et  Millet,  M.  Du  coeur  dans  la  grossesse  normale.  La 
Presse  Med.,  1898,  vol.  viS  p.  61. 

Vaquez  et  Nob6court.  De  la  pression  artgrielle  dans  I'eclampsie  puer- 
perale.  Bull,  et  Mem.  Soc.  m€d.  des  Hop.  de  Paris,  1897,  vol.  xiv, 
p.  117. 

Wiessner.     Ueber  Blutdruckuntersuchungen  wahrend  der  Menstruation 
und    Schwangerschaft.      Centralbl.    f.    Gynakol.,    1899,    vol.   xxiii, 
p.  1335. 
20 


INDEX 


Abbreviations,  list  of,  xv. 
Abdomen,  opemtions  on,  269. 

paracentesis  of,  340,  269. 
Abscess,  of  the  brain,  253. 
Addison's  disease,  237. 
Adrenalin,  223. 

in  haemorrhage,  273. 

in  shock,  277. 
Age,  influence  of,  108. 
Aged,    the,    muscular     exertion    in, 

123. 
Albuminuria,  cyclical,  183. 
Alcohol,  in  normal  man,  118. 

in  disease,  223. 
Amaurosis,  in  eclampsia,  289. 

in  lead  colic,  239. 

in  uraemia,  182. 
Amyl  nitrite,  in  cardio-vascular  dis- 
ease, 211. 

in  shock,  277. 
Anaemia,  236. 

cerebral,  139. 
Anaesthesia,  general,  262. 

general,  in  obstetrical  cases,  285. 

local,  263. 

spinal,  265. 
Aneurism,  189. 

relation  of,  to  hypertension,  152. 
Anger,  119. 
Angina  pectoris,  202. 

treatment  of,  214. 
Angio-sclerosis,  148,  188. 
Animals,  different,  blood-pressure  in, 

28. 
Aorta,  ligature  of,  23. 

disease  of,  143. 
Aortic  insufficiency,  194. 

stenosis,  196. 


Apparatus,  Dehio's,  208. 

Walden's,  71. 
Appendectomy,  269. 
Apoplexy,  cerebral,  152,  189,  248. 

cerebral,  operation  for,  278. 
Armlet,  adjustment  of,  56. 

influence  of  inner  wall  of,  55. 

influence  of  site  of  application  of,  59. 

width  of,  relation  to  limb,  57. 

cross-section  of,  Hill  and  Barnard's, 
54. 

cross-section  of,  Riva-Rocei's,  54. 

V.  Recklinghausen's,  57. 
Arrhythmia,  205. 
Arteries,  aneurism  of,  189. 

compression  of,  189. 

different,  blood-pressure  in,  .30. 

digital,  vaso-motor  changes  in,  68. 

dilatation  of,  150. 

disease  of,  143,  184. 

disease  of,  cerebral,  189,  248. 

disease  of,  treatment  of,  210. 

effect  of  hypertension  on,  150. 

hypertrophy  of,  151. 

not  all  contracted  or  dilated  at  the 
same  time,  24. 

rupture  of,  151. 

small,  dilatation  of,  19. 

thrombosis  of,  189. 
Artery,  manner  of  closure  of,  60. 

pulmonary,  blood-pressure  in,  31. 

wall   of,  influence  of,  in   measure- 
ments, 60. 
Arterio-capillary  fibrosis,  144. 
Arterio-sclerosis,  143,  184. 

influence  of,  in  measurements,  60. 
Ascites,  240. 
Asphyxia,  37. 

291 


292 


INDEX 


Aspiration,  of  effusions.  240. 
Asthma,  bronchial,  240. 

cardiac,  204. 
Attention,  mental,  119. 

Baths,  Brand,  221. 

in  normal  man,  124. 

Nauheim,  210. 
Basedow's  disease,  200. 
Blood-pressure,  as  a  guide  to  adequacy 
of  circulation,  161. 

as  a  guide  to  functional  ability  of 
heart,  161. 

diastolic,  criterion  of,  69. 

elements  of,  136. 

end,  little  greater  than  lateral,  65. 

factors  which  determine,  11, 

first  demonstrated,  3. 

high.    (See  Hypertension.) 

human,  direct  measurements  of,  29. 

limits  of,  normal,  108. 

limits  of,  pathological,  135. 

low.    (See  Hypotension.) 

mean,  how  calculated,  4,  35,  112. 

normal,  data  for,  110. 

records,  101. 

relation  of,  to  temperature,  160. 

relation  of,  to  pulse-rate,  160. 

systolic,  in  brachial  and  digital  ar- 
teries, 69. 

systolic,  criteria  of,  62,  64,  66. 

systolic,  inspiratory  fall  of,  208,  230. 

variations  of,  cardiac,  4,  5,  32,  109. 

variations  of,  diurnal,  113. 

variations  of,  in  different  individu- 
als, 108-112. 

variations  of,  in  the  same  individual, 
112-127. 

variations  of,  periodic,  32,  112. 

variations  of,  respiratory, 4, 5, 35,112. 

variations  of,  respiratory,  in  asthma, 
240. 

variations    of,  respiratory,   in    dis- 
ease, 208. 

variations  of,  respiratory,  in  diph- 
theria, 230. 

variations     of,     spontaneous    non- 
rhythmical,  37. 


Blood-pressure,  systolic  and  diastolic, 
measurement  of,  129. 
systolic  and  diastolic,  not  measured 

by  manometric  trace,  5. 
systolic  and    diastolic,  in    haemor- 
rhage, 28. 
systolic    and    diastolic,   in    normal 

animal,  32. 
systolic   and  diastolic,  relation  of. 
(See  Pulse-pressure.) 
Blood,  volume  of,  25. 
Bone,  operations  on,  268. 
Bradycardia,  205. 
Brain,  abscess  of,  253. 
absence  of  vaso-motor  nerves  in,  17. 
ansemia  of,  139. 
arterial  disease  of,  189,  248. 
compression  of,  139. 
cortex  of,  stimulation  of,  21. 
diseases  of,  248. 
tumors  of,  253. 
tumors  of,  operation  for,  273. 
Bronchitis,  chronic,  240. 

Cachexia,  237. 
Caffein,  139,  221. 
Camphor,  139,  221. 
Centres,  vaso-motor,  17,  18. 

vaso-motor,  in  cerebral  anaemia,  140. 

vaso-motor,  in  collapse,  155. 

vaso-motor,  in  shock,  157. 
Charts,  blood-pressure  and  pulse,  101. 
Cheync-Stokes  respiration,  205. 

in  cerebral  anaemia,  140,  141. 
Childhood,  acute  disease  in,  231. 
Children,  normal,  108. 
Chloroform,  262. 

in  obstetrical  cases,  285. 

in  puerperal  eclampsia,  288. 
Cholecystectomy,  269. 
Circulation,  adequacy  of,  blood-pres- 
sure as  a  guide  to,  161. 

arterial,  general  features  of,  9. 

splanchnic,  importance  of,  22. 

splanchnic,  in  artcrio-sclerosis,  143. 

splanchnic,  in  hypertension,  142. 
Closure,  of  artery,  manner  of,  60. 
Coagulation,  method  of  preventing,  3. 


INDEX 


203 


Cocain,  263. 
Cold,  124. 
Colic,  lead,  238. 
Collapse,  158. 

experimental  evidence  on,  155. 

in  obstetrical  cases,  286. 

in  pneumonia,  227. 

in  surgical  cases,  273. 

in  typhoid  fever,  219. 
Color,  of  skin,  change  of,  as  criterion, 

53,  66. 
Coma,  uraemic,  182. 
Compensation,  of  the  heart,  disturb- 
ance of,  197, 198. 
Compression,  cerebral,  139. 

cerebral,  operation  for,  271,  278. 

circular,  method  of,  54-62. 

of  an  artery,  189. 

of  limb,  in  measurements,  influence 
of,  66. 
Contraction,    muscular,    in    measure- 
ments, influence  of,  61. 
Convulsions,  epileptic,  256. 

uraemic,  182. 
Coronary  artery,  ligature  of,  12. 
Cortex,  cerebral,  stimulation  of,  21. 
Cranium,  operations  on,  271. 
Crises,  vascular,  in  tabes,  248. 

visceral,  in  tabes,  247. 
Criteria  not  in  clinical  use,  73. 

the  several,  validity  of,  62-73. 

of  diastolic  pressure,  51,  69. 

of  systolic  pressure,  45,  53,  62. 

Data,   tabulated,    for    normal    blood- 
pressure,  110. 
Death,  sudden,  during  operation,  267. 
Depressor  fibres  in  sensory  nerves,  21. 
Depressor  nerve,  14,  21. 
Diabetes,  235. 
Diagnosis,  of  angina  pectoris,  203. 

of  cerebral  hiemorrhage,  249. 

of    collapse,    in    acute    disease    in 
childhood,  231. 

of  collapse,  in  obstetrical  cases,  287. 

of  collapse,  in  pneumonia,  227. 

of  collapse,  in  surgical  cases,  273. 

of  collapse,  in  typhoid  fever,  219. 


Diagnosis,  of  combined  valve-lesions, 
195. 

of  epileptic  coma,  256. 

of  head  injuries,  277. 

of  lead  poisoning,  239. 

of  nephritis,  172,  178. 

of  nephritis  in  pregnancy,  284. 

of  peritonitis,  278. 

of  puerperal  eclampsia,  287. 

of  shock,  273. 

of  stupor,  in  circular  insanity,  256. 

of  typhoid  haemorrhage,  219. 

of  typhoid  perforation,  220. 

of  uraemia,  182. 
Diarrhoea,  acute,  in  childhood,  231. 
Digitalin,  in  acute  disease  in  child- 
hood, 231. 

in  hemorrhage,  273. 

in  shock,  277. 

in  typhoid  fever,  221. 
Digitalis,  139,  210. 
Dilatation  of  sphincter  ani,  267. 
Diphtheria,  230. 
Disease,  blood-pressure  in,  133-166. 

cardio-vascular,  169-216. 

cardio-vascular,  after  typhoid  fever, 
226. 

cardio-vascular,   effect  of    exertion 
in,  208. 

of  the  arteries,  184. 

of  the  heart,  muscular,  191. 

of  the  heart,  nervous,  200. 

of  the  heart,  valvular,  194. 
Diseases,  acute  infectious,  216. 

acute  infectious,  in  childhood,  231. 

chronic  infectious,  231. 

chronic,  with    impaired    nutrition, 
235. 

internal,  167-244. 

mental,  253-256. 

nervous,  245-258. 

nervous,  functional,  256. 
Dogs,  blood-pressure  in,  29. 

laparotomy  on,  269. 

Eclampsia,  puerperal,  287. 
EflEusion,  peritoneal,  240. 
pleural,  240. 


294 


INDEX 


Elasticity,  of  the  arterial  wall,  24. 

of  the  arterial  wall,  necessity  for,  10. 

error,  in  measurements,  56. 
Elements,  functional  and  essential,  of 

blood-pressure,  136. 
Embolism,  cerebral,  353. 
Emphysema,  340. 
Empyema,  operation  for,  364. 
Energy,  of  the  heart,  11-16. 
Endocarditis,  acute,  200. 
Epilepsy,  256. 

Ergotin,  in  h.-emorrhage,  273. 
Error,  elasticity,  in  measurements,  56. 
Erythrol     tetranitrate,    in    insomnia, 
256. 

tetranitrate,  in  melancholia,  255. 
Ether,  262. 

not  a  stimulant,  223. 

nitrous,  spirits  of,  211, 
Excitement,  119. 
Exertion,  mental,  119. 

muscular,  in  animals,  39. 

muscular,  in  man,  121. 

muscular,  in  the  aged,  123. 

muscular,    in    cardio-vascular    dis- 
ease, 208. 

muscular,  in  tuberculosis,  232. 

Factors  which  determine  blood-pres- 
sure, 11-28. 

Fever,  160. 
typhoid,  217. 

Fibrosis,  arterio-capillary,  144. 

Fingers,    warmth    of,    necessary    for 
measurements,  68. 

Flow  of  liquids  through  tubes,  9. 

Fright,  119. 

Functional  nervous  conditions,  256. 

Ganglion,  Gasserian,  operation  on,  271. 
Genito-urinary  operations,  272. 
Goitre,  exophthalmic,  200. 
Gout,  239. 
Graphic  method,  3. 
Graves's  disease,  200. 
Gravity,    influence    of,    in    measure- 
ments, 59. 
Gynaecological  operations,  269. 


Ha?modynamometer,  Oliver's,  53. 
IL-cnioptysis,  234. 
IIa?morrhage,  cerebral,  189,  248. 

cerebral,  operation  for,  278. 

experimental,  26. 

in  medical  cases,  241. 

in  obstetrical  cases,  286. 

in  surgical  cases,  272. 

in  typhoid  fever,  219. 

intracranial,  operation  for,  271,  278. 

middle  meningeal,  271,  278. 

pulmonary.     (See  Haemoptysis.) 
Head,  injuries  to,  277. 
Heart,  disease  of,  muscular,  191. 

disease  of,  nervous,  200. 

disease  of,  valvular,  194. 

disease  of,  eflFect  of  exertion  in,  208. 

disease    of,   in    secondary   syphilis, 
234. 

disease  of,  treatment  of,  210. 

effect  of  hypertension  on,  148. 

energy  of,  11-16. 

functional  ability  of,  blood-pressure 
as  a  guide  to,  161. 

hypertrophy  of,  in  arterio-sclerosis, 
143. 

hypertrophy  of,  in  hypertension,  143. 

hypertrophy  of,  in  nephritis,  144. 

hypertrophy  of,  in  pregnancy,  284, 

rate  of,  13. 

reserve  force  of,  15. 

work  of,  blood-pressure  as  a  guide 
to,  161. 
Heat,  124. 

Hemiplegia,  189,  252. 
Hydrocele,  excision  of,  265. 
Hypertension,  absence  of,  in  angina 
pectoris,  203. 

absence  of,  in  arterial  disease,  143, 
185. 

absence  of,  in  cardiac  disease,  192. 

absence  of,  in  nephritis,  acute,  178. 

absence  of,  in  nephritis,  chronic  in- 
terstitial, 172. 

absence  of,  in  nephritis,  other  forms, 
177. 

dangers  of,  for  the  arteries,  150, 

dangers  of,  for  the  heart,  148. 


INDEX 


205 


Hypertension,  diagnosis  of,  137. 

effect  of,  on  the  arteries,  150. 

effect  of,  on  the  heart,  148. 

essential,  142. 

essential,  causes  of,  143. 

false,  in  aortic  insufficiency,  194. 

functional,  causes  of,  138. 

from  CGcain,  264. 

from  ether,  early  stages,  262. 

in  angina  pectoris,  208. 

in  angio-sclerosis,  148. 

in  apoplexy,  189,  248. 

in  arterio-sclerosis,  143,  185. 

in  asphyxia,  37. 

in  asthma,  240. 

in  bronchitis,  chronic,  240. 

in  cerebral  compression,  139,  278. 

in  cerebral  hiemorrhage,  189,  248. 

in  cerebral  thrombosis,  252. 

in  circular  insanity,  256. 

in  crises,  visceral,  of  tabes,  247. 

in  diabetes,  235. 

in  disease  of  heart,  192. 

in  emphysema,  240. 

in  exophthalmic  goitre,  200. 

in  gout,  239. 

in  insomnia,  256. 

in  labor,  285. 

in  lead  poisoning,  238. 

in  melancholia,  254. 

in  nephritis,  144,  169,  177,  179. 

in  neurotics,  257. 

in  obstetrical  operations,  286. 

in  peritonitis,  acute,  278. 

in  pneumonia,  226. 

in  pregnancy,  284. 

in  puerperal  eclampsia,  287. 

in  trigeminal  neuralgia,  256. 

in  typhoid  perforation,  220. 

treatment  of,  210. 
Hypertrophy,  of  the  heart,  in  arterio- 
sclerosis, 143. 

of  the  heart,  in  hypertension,  143. 

of  the  heart,  in  nephritis,  144. 

of  the  heart,  in  pregnancy,  284. 
Hypnotics,  256. 
Hypotension,  causes  of,  152. 

gangers  of,  18,  159. 


Hypotension,  effects  of,  18,  159. 
from  chloroform,  262. 
in  acute  disease  in  childhood,  231. 
in  anaemia,  236. 
in  cachexia,  237. 
in  cerebral  compression,  terminal, 

141,  249,  277. 
in  cerebral  hsemorrhage,  terminal, 

249. 
in  collapse,  153. 

in  collapse,  in  obstetrical  cases,  286. 
in  collapse,  in  surgical  cases,  273. 
in  collapse,  in  typhoid  fever,  219. 
in  diabetes,  236. 
in  diphtheria,  230. 
in  general  paresis,  253. 
in  hsemorrhage,  in  obstetrical  cases, 

286. 
in  haemorrhage,  in  surgical  cases,  272. 
in  haemorrhage,   in  typhoid  fever, 

219. 
in  lightning  pain,  of  tabes,  247. 
in  mania,  acute,  255. 
in  myasthenia  gravis,  253. 
in  peritonitis,  terminal,  278. 
in  pneumonia,  226. 
in  secondary  syphilis,  234. 
in  shock,  153,  273. 
in  tuberculosis,  231. 
in  typhoid  fever,  217. 
terminal,  153. 
treatment  of,  in  medical  cases,  221, 

231. 
treatment  of,  in  surgical  cases,  276. 
Hysteria,  257. 

Iodides.    (See  Potassium  Iodide.) 

Incision,  265. 

Individual,     normal,     variations     of 

blood-pressure  in,  112-127. 
Individuals,    different,   variations    of 

blood-pressure  in,  108-112. 
Infections,  acute,  216. 
Influenza,  230. 

Infusion,  saline,  in  acute  disease  in 
childhood,  231. 
saline,  in  hemorrhage,  272. 
saline,  in  shock,  277, 


296 


INDEX 


Innervation,  double,  of  arteries,  33. 
Insanity,  254. 

circular,  255. 
Insomnia,  25G. 
Intestine,  manipulation  of,  269. 

mucous  membrane  of,  irritation  of, 
269. 

resection  of,  269. 
lodipin,  in  lead  poisoning,  238. 
Irregularity,  of  the  heart,  205. 

Kidneys,  disease  of,  169. 

disease  of,  amyloid,  177. 

disease  of,  cardiac  liypertrophy  in, 
144. 

disease  of,  hypertension  in,  144. 

disease  of,  treatment  of,  210. 
Kymographion,  3. 

Labor,  285. 
Laparotomy,  269. 
Lead-poisoning,  238. 
Limits,     normal,     of    blood-pressure, 
108. 
pathological,  of  blood-pressure,  135. 
Liquids,  flow  of,  through  tubes,  9. 
Locomotor  ataxia,  247. 

Malaria,  230. 

Man,  normal,  blood-pressure  in,  105- 

132. 
Mania,  acute,  255. 
Manipulation,  of  nerves,  in   surgical 

operations,  267. 
Manometer,    mercurial,    first    intro- 
duced, 3. 

mercurial,  errors  of,  5. 

mercurial,  proper  calibre  of,  5. 

mercurial,  compensated,  6. 

elastic,  6. 

maximum  and  minimum,  6. 

Gumpreclit's,  80. 

how  filled,  103. 
Marasmus,  231. 
Meals,  117. 

Measurement,    direct,  of   blood-])res- 
sure,  1-6. 

indirect,  of  blood-pressure,  41-74. 


Mediastinum,  tumor  of,  191. 

Mehmcholia,  254. 

Meningitis,  253. 

Menstruation,  in  normal  women,  127. 

in  hysterical  women,  257. 
Mental  activity,  119. 
Method,  graphic,  3. 

of  circular  compression,  54-62. 

V.  Recklinghausen's,  73. 
Methods,  sphygmographic,  45,  73. 

wliich  apply  pressure  through  solid 
bio.  k,  45. 
Mitral  disease,  198. 
Muscles,  contraction  of,  influence  of, 

in  measurements,  61. 
Myasthenia  gravis,  253. 
Myocarditis,  191. 

Narcosis,  surgical,  262. 
Nephritis,  acute,  178. 

chronic  diffuse,  177. 

chronic  interstitial,  169. 

chronic  parenchymatous,  177. 
Nerve,  anterior  crural,  stimulation  of, 
21. 

chorda  tympani,  stimulation  of,  19. 

depressor,  14,  21. 

sciatic,  stretching,  266. 

sciatic,  stimulation  of,  21. 

superior  laryngeal,  cocainization  of, 
276. 

superior  laryngeal,  manipulation  of, 
267. 

vagus,  12,  20. 
Nerves,  manipulation  of,  267. 

sensory,  stinmlation  of,  21. 

sensory,  depressor  fibres  in,  21. 

splanclinic,  importance  of,  22. 

splanclinic,  section  of,  23. 

vaso-constrictor,  17. 

vaso-dilator,  17,  18. 
Nerve-trunks,  cocainization  of,  276. 

irritation  of,  266. 

section  of,  268. 
Neuralgia,  trigeminal,  256. 
Neurasthenia,  257. 
Neuropathic  individuals,  257. 
Neuroses,  cardiac,  200. 


INDEX 


297 


Nitroglycerin,  in  cardio-vascular  dis- 
ease, 311. 
in  melancholia,  255. 
in  shock,  277. 
Nitrous  oxide,  263. 

Nutrition,  impaired,  chronic  diseases 
with,  235. 

Obstetrics,  blood-pressure  in,  281-289. 
Occupation,  109. 
Odors,  119. 

ffidema,    influence    of,    in    measure- 
ments, 61. 

of  the  lungs,  205. 
Operations,  genito-urinary,  272. 

gynaecological,  269. 

obstetrical,  286. 

peripheral,  265. 

surgical,  261. 
Osteomyelitis,  operation  for,  267. 
Output,  of  the  ventricles,  12. 

Pain,  120,  139,  256,  264. 
Pains,  labor,  285. 

lightning,  of  tabes,  247. 
Palpation,  of  the  pulse,  44. 
Paracentesis,  of  the  abdomen,  240,  269. 

of  the  thorax,  240,  271. 
Paraldehyde,  in  insomnia,  256. 
Paralysis,  general,  of  the  insane,  253. 

vaso-motor,  15,  18. 

vaso-motor,  in  collapse,  156. 

vaso-motor,  in  shock,  158. 
Paresis,  general,  253. 
Pelotte,  V.  Basch's,  46. 

Potain's,  48.  , 

Perforation,  in  typhoid  fever,  220. 
Peritonitis,  acute,  278. 

perforative,  in  typhoid  fever,  220. 
Pertussis,  231. 
Pneumatic  ring,  Gartner's,  55,  82. 

suit,  Crile's,  in  acute  disease,  226. 

suit,  Crile's,  in  shock,  277. 
Pneumonia,  226. 

in  childhood,  231. 
Potassium  iodide,  in  cardio-vascular 
disease,  211. 

in  lead  poisoning,  239. 


Poisoning,  lead,  238. 
Posture,  115. 

in  cyclical  albuminuria,  184. 
Practice,  in  muscular  exertion,  122. 
Pregnancy,  284. 
Pressor  effect,  21. 

fibres,  21. 
Pressure,  atmospheric,  38,  126. 

end,  how  measured,  10. 

intra-abdominal,  15. 

lateral,  how  measured,  10. 

total.     (See  End-pressure.) 
Prophylaxis,  of  shock,  276. 
Prostatectomy,  272. 
Prognosis,  in  acute  disease  in  child- 
hood, 231. 

in  angina  pectoris,  203. 

in  cerebral  hjemorrhage,  249. 

in  diphtheria,  230. 

in  general  paresis,  253. 

in  head  injuries,  278. 

in  nephritis,  173,  178. 

in  pneumonia,  227. 

in  puerperal  eclampsia,  287. 

in  surgical  operations,  262. 

in  typhoid  fever,  217. 

in  tuberculosis,  234. 

in  uraemia,  182. 
Pulse,  palpation  of,  44. 

obliteration  of,  as  criterion,  45,  62. 

return  of,  as  criterion,  62. 

alternating,  205 

different  in  two  arms,  190. 

paradoxical,  208. 
Pulse-rate,  relation  of,  to  blood-pres- 
sure, 13,  160. 
Pulse-volume,  during  excitement,  119. 

during  exertion,  122. 

in  aged,  129. 

in  disease.    (See  Pulse-pressure.) 
Pulse-wave,   return    of,    under    com- 
pression, 62. 

return  of,  "letting  the  cuff  feel," 
64. 
Pulse-waves,  rudimentary,  63. 

well-developed,  63. 
Pulsation,  maximum,  as  criterion,  51, 
69. 


298 


INDEX 


Pulse-pressure,  importance  of,  35, 129. 

not  measured  by  raanonietric  trace,  5. 

in  normal  animal,  32. 

during  excitement,  119. 

during  exertion,  132. 

in  alternating  pulse,  205. 

in  aortic  insufficiency,  195. 

in  arterial  disease,  185. 

in  bradycardia,  205. 

in  cyclical  albuminuria,  184. 

in  haimorrhage,  28. 

in  hypertension,  25,  136. 

variation  of,  with  posture,  116. 
Piierperium,  the,  287. 
Pulmonary,  artery,  blood-pressure  in, 

31. 
Psychical  state,  119. 

in  melancholia,  254. 
Psychoses,  the,  254. 

Rate,  of  heart,  13,  160. 

Records,    blood-pressure    and    pulse, 

101. 
Reflex,  pelvic,  286. 
Reflexes,  vascular,  21. 
Resistance,  peripheral,  10,  16. 

peripheral,  blood-pressure  as  a  guide 
to,  161. 
Respiration,  Cheyne-Stokes,  205. 
Cheyne-Stokes,  in  cerebral  ana?mia, 
140,  141. 
Rest,  unaccustomed,  116. 
Retraction,  forced,  267. 
Rheumatism,  230. 
Rickets,  231. 

Ring,  pneumatic,  Gartner's,  55,  82. 
pneumatic,  adjustment  of,  56. 
pneumatic,   width    of,    relation    to 
finger,  59. 

Sepsis,  230. 

Sex,  108. 

Shock,  153,  157,  273. 

Sight  perceptions,  119. 

Size,  bodily,  112. 

Skull,  fracture  of,  277. 

operations  on,  271. 
Sleep,  116. 


Sodium  bicarbonate,   in  saline   in.fu- 
sion,  273. 
carbonate,    solution    of,    to    retard 

coagulation,  3. 
nitrite,   in    cardio-vascular  disease, 
211. 
Sjihincter  ani,  dilatation  of,  267. 
Spinal  cord,  destruction  of,  18. 
section  of,  17. 
diseases  of,  247. 
Spinal  canal,  operations  on,  271. 
Sjiiritus  etheris  nitrosi,  in  cardio-vas- 
cular disease,  211. 
Species,  animal,  blood-pressure  in  dif- 
ferent, 28. 
Splanchnic  circulation,  importance  of, 
22. 
circulation^  in  hypertension,  142. 
nerves,  22,  23. 

vessels,  dilatation  of,  from  depres- 
sor reflex,  21. 
vessels,  constriction  of,  from  depres- 
sor reflex,  22. 
vessels,  in  arterio-sclerosis,  143. 
Siihygmomanometer,  care  of,  103. 
choice  of,  102. 
development  of,  46. 
leaks  in,  104. 
V.  Basch's,  46. 
Behier's,  45. 
Bloeh's,  45. 
Cheron's,  45. 
Cook's,  80. 
Erlangcr's,  93, 
Forster's,  45. 
V.  Frey's,  45. 
Giirtner's,  82. 
Hill  aiul  Barnard's,  84. 
Hill  and  Barnard's,  pocket,  53. 
Hoorweg's,  45. 
Illirthle's,  51,  73. 
Jane  way's,  89. 
Landois's,  45. 
Levaschoff's,  45. 
Maroy's,  first,  50. 
Marey's,  second,  51. 
Martin's,  80. 
Mosse's,  51, 


INDEX 


299 


Sphyginomanoracter,  Oliver's,  53. 
Pliiladelphien's,  45. 
Potain's,  48. 

V.  Recklinghausen's,  73. 
Riva-Rocci's,  78. 
Stanton's,  87. 
Verdin's,  45. 
Vieroi-dt's,  43. 
Waldenburg's,  45. 
Sphygmomanometers,  the  modern,  75- 
104. 
comparison  of  results  obtained  with, 
100. 
Sphygmometer.    (See  Sphygmomanom- 
eter.) 
Sphygmometrographe,       Philadelphi- 

en's,  45. 
Strychnin,  in  acute  disease  in  child- 
hood, 231. 
in  collapse,  in  obstetrical  cases,  287. 
in  collapse,  in  surgical  eases,  276. 
in  collapse,  in  typhoid  fever,  221. 
in  haemorrhage,  273. 
in  shock,  276. 
Suggestions,    practical,     for    use    of 

sphygmomanometer,  102. 
Suit,  pneumatic,  Crile's,  in  acute  dis- 
ease, 226. 
pneumatic,  Crile's,  in  shock,  277. 
Sulphonal,  in  insomnia,  256. 
Suprarenal  extract,  223. 
Superior  laryngeal   nerve,   injury  to, 

267. 
Surgery,  blood-pressure  in,  259-279. 
Sweating,  during  anaesthesia,  262. 
during  exertion,  123. 
to  reduce  hypertension,  214. 
Syphilis,  secondary,  234. 

Tabes  dorsalis,  247. 
Tachycardia,  paroxysmal,  201. 
Taste  perceptions,  119. 
Temperament,  112. 
Temperature,  external,  124. 
bodily,   relation   of,  to  blood-pres- 
sure, 160. 
Therapeutics.     (See  Treatment.) 
Throb,  subjective,  as  criterion,  67. 


Thoracotomy,  264. 
Thorax,  operations  on,  271. 

paracentesis  of,  240,  271. 
Thrombosis,  arterial,  189. 

cerebral,  252. 
Tissues,  influence  of,  in  measurements, 

56. 
Tobacco,  118. 
Tone,  vaso-motor,  16-24. 

vaso-motor,  in  collapse,  155. 

vaso-motor,  in  shock,  157. 

vaso-motor,  variations  of,  local,  19. 

vaso-motor,  variations  of,  reflex,  21. 
Tonometer,  Gartner's,  82. 
Traction,  in  operations,  267. 

on  child  during  labor,  286. 
Trional,  256,  257. 
Trace,  manometric,  the  normal,  4. 
Training,  physical,  122. 

physical,   in    cyclical   albuminuria, 
184. 
Transfusion,  26,  28. 
Traube-Hering  waves,  36. 

in  man,  112. 

in  cerebral  anaemia,  140,  141. 
Treatment,  of  acute  disease,  221. 

of  acute  disease  in  childhood,  231. 

of  cardio-vascular  disease,  210. 

of  hasmorrhage,  272. 

of  hypertension,  210. 

of  shock,  276. 

of  typhoid  fever,  221. 
Tuberculosis,  231. 

in  childhood,  231. 
Tubes,  flow  of  liquids  through,  9. 
Tumor,  of  the  brain.  253. 

of  the  brain,  operation  for,  272. 

of  the  breast,  operation  for,  268. 

of  the  mediastinum,  191. 
Typhoid  fever,  217. 

late  effects  of,  226. 

Uraemia,  182. 

treatment  of,  214. 
Uterus,  operations  on,  269. 

Vagus,  stimulation  of  central  cut  enci 
of,  30, 


300 


INDEX 


Vagus,  stimulation  of  peripheral  cut 

end  of,  13. 
Variations,   of    blood-pressure.      (See 

Blood-pressure.) 
Vaso-constrictor  nerves,  17. 
Vaso-dilator  nerves,  17,  18. 

drugs,   in    cardio-vascular    disease, 
311. 

drugs,  in  puerperal  eclampsia,  388. 

drugs,  in  shock,  377. 
Vaso-motor  centres,  17,  18. 

centres,  in  asphyxia,  37. 

centres,  in  cerebral  antemia,  140. 

centres,  in  collapse,  155. 

centres,  in  shock,  155,  157. 

paralysis,  effect  of,  on  heart,  15. 

tone,  the,  16-34. 

tone,  in  collapse,  155. 

tone,  in  shock,  157. 

tone,  variations  of,  local,  19. 

tone,  variations  of,  reflex,  31. 
Velocity  of  stream,  a  component  of 

end  pressure,  10. 
Venesection,   in   cardio-vascular    dis- 
ease, 314. 

in  puerperal  eclampsia,  389. 


Ventricle,  right,  maximum   pressure 

in,  33. 
Ventricles,  output  of,  13. 
Verification,  of  criterion  of  maximum 
pulsation,  69. 
of  criterion  of  return  of  color,  66. 
of  criterion  of  return  of  the  pulse, 

63. 
of  method  of  circular  compression, 
55. 
VertebrjB,  operations  on,  371. 
Vessels,  cerebral,  disease  of,  189. 
splanchnic,  31,  23. 
splanchnic,  in  arterio-sclerosis,  143. 
splanchnic,  in  hypertension,  148. 
Volume,    of    the    circulating    blood, 
35. 
output  of  the  ventricles,  13. 

Waves,  Traube-Hering,  36,  113. 
Traube-IIering,  in  cerebral  anaemia, 
140,  141. 
Work,  muscular,  39,  121. 
muscular,  in  cardio-vascular  disease, 

308. 
muscular,  in  the  aged,  132. 


(1) 


THE   END 


THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE. 

By  WILLIAM   OSLER,   M.  I)., 

Fellow  of  the  Royal  College  of  Physicians,  London  ;   Professor  of  Medicine  in  the  Johns  Hopkins 
University,  and  Physician  in  Chief  of  the  Johns  Hopkins  Hospital,   Baltimore  ;    formerly 
Professor  of  the   Institutes  of  Medicine,  McGill  University,   Montreal  ;    and  Pro- 
fessor of  Clinical  Medicine  in  the  University  of  Pennsylvania,  Philadelphia. 

THE     WORK    HAS     BEEN    REVISED,     REWRITTEN,     RESET,     ENLARGED,     AND 
BROUGHT   UP    TO  DATE  IN  ALL  DEPARTMENTS. 

Fifth  Edition.     8vo,  1182  pages.     Cloth,  $s.50  ;    half  morocco,  $7.00. 

Sold  only  hy  Subscription. 

In  preparing  the  revision  the  author  has  depended  not  only  upon  his  own 
inexhaustible  resources,  but  has  been  assisted  by  men  who  are  especially  quali- 
fied in  certain  lines  of  medical  practice  and  in  pathological  investigation.  He 
has  in  all  sections  tried  to  maintain  the  thoroughly  practical  character  of  the 
work,  as  a  guide  in  diagnosis,  symptomatology,  and  treatment.  The  work  is 
already  the  standard  text-book  of  nearly  every  reputable  medical  college  in  this 
country,  being  recognized  and  accepted  as  a  safe,  sure,  and  scientific  teacher  for 
the  student  of  medicine,  as  it  is  also  an  indispensable  work  of  reference  and  a 
reliable  guide  to  the  physician  who  wishes  to  occupy  a  place  in  the  front  rank 
of  medical  practice. 

"The  first  edition  was  great,  the  second  greater,  and  this  last  greatest  of 
all. " — Cincinnati  Lancet-Clinic. 

"  There  are  few  books  which  receive  professional  confidence  and  esteem  to 
the  extent  of  that  received  by  Dr.  Osier's  well-known  work,  for  three  large 
editions  have  been  presented  to  us  in  a  period  of  about  six  years." — Thera- 
peutic Gazette. 

'■We  have  little  to  add  to  our  notice  of  the  second  edition  {vide  ]ouma\, 
November  30,  1895,  page  966).  Tne  criticisms  then  made  hold  good  now, 
but  we  regarded  the  work  as  one  of  the  ablest  contributions  to  the  literature 
of  the  subject  in  this  country — an  opinion  which  we  still  hold." — Journal  of 
the  American  Medical  Association. 

"The  work,  like  former  editions,  is  thoroughly  practical  in  its  character, 
fully  up  with  the  times  and  down  to  date,  and  is  a  safe  guide  to  all  practitioners 
who  may  consult  its  pages.  The  student  of  medicine,  whose  time  is  so  much 
occupied  by  the  tremendous  amount  of  knowledge  he  is  expected  to  master 
before  graduation,  will  find  here  exhausfiveness  without  verbosity  and  a  plain 
matter-of-fact  method  of  discussing  the  characters  of  different  diseases,  that  can 
not  fail  to  instruct  without  wearying." — Journal  of  Medicine  and  Science. 

D.  APPLE  TON  AND  COMPANY,  NEW  YORK. 


THE  SURGICAL  DISEASES 

OF  THE  GENITO-URINARY 

ORGANS. 

By  E.   L.   KEYES,  A.  M.,  M.  D.,  LL  D., 

Consulting  Surgeon  to  the  Bellevue  and  the  Skin  and  Cancer  Hospitals ;  Surgeon 
to  St.  Elizabeth  Hospital ;   formerly  Professor  of  Genito-Urinary  Sur- 
gery, Syphilology,  and  Dermatology  at  the  Bellevue  Hospital 
Medical  College,  etc. ;  and 

E.  L   KEYES,  Jr.,   A.  B.,  M.  D.,  Ph.D., 

Lecturer  on  Genito-Urinary  Surgery,  New  York  Polyclinic  Medical  School  and 
Hospital;  Assistant  Visiting  Surgeon  to  St.  Vincent's  Hospital  ;  Physi- 
cian to  the  Venereal  Clinic,  Out-Patient   Department  of  the 
House  of  Relief  of  the  New  York  Hospital,  etc. 

Cloth,  $5.00;  half  leather,  $5.50.     Sold  only  by  Subscription. 

WITH    ONE    HUNDRED    AND    SEVENTY-FOUR    ILLUSTRATIONS    IN    THE    TEXT 
AND    ELEVEN     PLATES,    EIGHT    OF    WHICH    ARE    IN    COLORS. 

"It  is  certainly  refreshing  that  a  man  of  the  experience  and  ability  of  the 
author  of  this  volume  has  culled  from  this  mass  of  literature  the  essentials,  and 
given  us  in  a  well-planned  volume  the  gist  of  the  entire  subject. 

"The  book  is  systematically  arranged,  and  each  subject  is  taken  up  and 
dealt  with  in  a  way  that  makes  it  easily  accessible  to  the  busy  practitioner. 
The  style  is  explicit  and  never  verbose,  which,  with  the  fine  vein  of  humor  run- 
ning through  it,  makes  it  very  enjoyable  reading." — Northwestern  Lancet. 

"Gonorrhea  is  gone  into  more  extensively  than  in  any  other  work." — 
Denver  Medical  Times. 

"  As  a  text-book  on  Genito-Urinary  Surgery  it  stands  at  the  head  of  the 
publications  on  the  subject  in  the  English  language.  Our  readers  wishing  an 
up-to-date  work  on  the  subject  can  not  do  better  than  to  buy  this  latest  and 
newest  work." — Medical  Century. 

"  The  book  is  well  illustrated,  well  printed,  well  arranged,  and  will  be  more 
popular  than  its  predecessors." — Chicago  Medical  Recorder. 

"  The  chapters  on  the  affections  of  the  posterior  urethra,  prostate  and  semi- 
nal vesicles  are  especially  good,  and  many  '  pointers '  are  found  in  the  chapter  on 
the  'Treatment  of  Urethral  Inflammation  and  their  Immediate  Complications.'  " 
— Canada  Medical  Record. 

"This  is  a  good  book  on  an  important  subject.  Within  the  compass  of 
800  pages  it  gives  a  comprehensive  treatment  of  the  various  diseases  of  this 
special  branch  of  surgery,  and,  while  not  discarding  the  good  of  the  older  work, 
it  embraces  all  that  is  new  in  this  field."— yowrj/j/  of  Medicine  and  Science. 

"This  is  so  well  written  as  to  be  exhaustive  in  character,  and  needs  little 
or  no  comment  from  the  reviewer  further  than  to  mention  its  completeness  in 
every  particular." — Cincinnati  Lancet-Clinic. 

D.    APPLETON    AND    COMPANY,    NEW    YORK. 


"A   TECHNICAL    ROOK   OF  'BROAD   USEFULNESS." 

— The    Times,  New  York. 

THE  LAW  IN  ITS  RELATIONS 
TO  PHYSICIANS 

By  ARTHUR    N.    TAYLOR,    LL.B. 

Of  the  New  York  Bar 
NEIV    EDITION,    T^EVISED    AND    ENLARGED 

i2mo.     Cloth.     Price,  $2.00 


"  Rarely  has  it  been  our  privilege  to  examine  a  bookwhich  so  clearly  seems 
to  just  fill  a  demand  as  this  one  does.  The  physician  must  ever  and  again 
recur  to  the  thought  that  by  some  slip  he  may  expose  himself  to  a  suit  whose 
loss  will  mean  his  financial  ruin.  The  average  physician  does  not  know  in  any 
adequate  way  just  what  can  legally  be  expected  of  him  by  his  patient.  Nor 
can  he  find  out  without  great  effort  and  probably  expense.  Neither,  on  the 
other  hand,  does  he  know  what  rights  he  has  in  the  courts.  If  called  into 
court  he  must  submit  utterly  to  the  advice  of  his  attorney.  It  is  to  meet  these 
conditions  that  this  book  is  issued.  The  author  quotes  fully  of  cases,  decisions 
and  opinions  of  leading  courts  and  jurists  everywhere,  but  especially  in  the 
various  states.  It  is  information  such  as  the  physician  needs  in  his  ordinary 
practice  in  order  to  protect  himself,  his  reputation,  and  his  family.  Of  course, 
unusual  cases  will  come  up,  but  if  we  know  the  principles  underlying  them  we 
may  act  much  more  wisely.  We  believe  the  book  will  have  a  very  wide 
circulation  here  in  New  England,  a  success  which  it  has  already  achieved  in 
New  York." — Annals  of  Gyncecology  and  Pediatrics,  Boston. 

"  Every  physician  should,  unless  conversant  with  the  law,  avail  himself 
of  the  contents  of  this  book,  and  he  will  find  himself  better  prepared  to  meet 
the  conditions  and  circumstances  involving  legal  complications  into  which  any 
of  us  are  liable  to  find  ourselves  drawn." 

— Journal  of  Nervous  and  Mental  Diseases,  New  York. 

"  This  volume  is  indeed  a  most  valuable  one,  because  physicians  should 
have  an  idea  of  the  law  as  it  regards  them.  For  often  it  is  found  that  physicians 
are  ignorant  of  the  most  elementary  principles  of  the  law  ;  and  this  is  not 
all,  they  do  not  understand  the  law  which  refers  to  them.  This  book  is  an 
excellent  treatise  and  one  which  brings  out  all  the  facts  which  it  is  important 
that  a  physician  should  know.  We  advise  all  physicians  to  buy  this  book  and 
read  it  through.  In  a  thousand  and  one  instances  it  will  be  found  of  the 
greatest  value." — Medical  Progress,  Louisville. 

D.    APPLETON    AND    COMPANY,    NEW    YORK. 


GYN/ECOLOGY 


A    Text  -  Book    for   Students 
and  a  Guide  for  Practitioners 

By  WILLIAM    R.    PRYOR,    M.D. 

Professor  of  Gynaecology'  in  the  New  York  Polyclinic  Medical  School ;  Attending 

GjTiaecologist  New  York  Polyclinic  Hospital ;  Consulting  Gynaecologist  St. 

Vincent's  Hospital,  New  York  City  Hospital,  and  St.  Elizabeth's 

Hospital ;    Membre  Fondateur  Congress  International  de 

Gynaecologie  et  d'Obstetrique  ;  Fellow  of  the  American 

G}Tiaecological   Society ;    Fellow    New    York 

Academy  of  Medicine 

Sold  only  by  Subscription.     Cloth,  $3.50 

"  The  author  of  this  book  has  had  a  large  experience,  both  as  a  teacher 
and  an  operative  surgeon,  and  we  would  expect  him  to  produce  an  excellent 
treatise.  This  he  has  undoubtedly  done,  but  he  has  also  accomplished  more, 
for  the  book  is  especially  well  written,  being  very  readable,  and  at  the  same 
time  clear  and  concise,  so  that  both  students  and  practitioners  will  find  it  a 
valuable  guide  in  this  important  field.  The  division  of  the  work  into  two  parts 
is  admirable,  the  first  treating  of  diseases  and  the  second  giving  the  operative 
procedures,  as.it  enables  the  reader  to  quickly  find  what  he  is  looking  for.  The 
chief  features  of  the  book  are  the  avoidance  of  extraneous  topics,  the  omission 
of  minute  anatomy  and  bacteriologic  examinations,  and  the  prominence  given 
to  non-operative  measures  as  well  as  operative  treatment.  The  illustrations  are 
many  and  artistic,  and  add  to  the  value  of  the  text,  and  the  general  make-up  of 
the  book  is  a  credit  to  this  well-known  firm  of  publishers.  Those  who  buy 
this  book  will  not  be  disappointed  in  it." — -Journal  of  Medicine  and  Science. 

"  The  literarj'  style  is  good.  The  author  has  an  easy  and  graceful  mode  of 
expression,  and  thereby  greatly  enhances  the  usefulness  of  his  book.  The 
illustrations  are  very  artistic  and  are  mostly  original.  It  has  not  been  our 
fortune  to  examine  any  book  that  will  better  repay  study  than  this  one  from 
the  pen  of  Dr.  Prj'or.  We  congratulate  both  author  and  publisher  upon  the 
results  of  their  efforts  to  give  the  medical  profession  a  really  good  book. 

"  Even.-thing  is  found  in  it  that  is  likely  to  be  met  with,  even  by  the 
specialist.  He  devotes  considerable  space  to  the  treatment  of  disease,  and  the 
performance  of  operations  by  the  vaginal  route,  yet  he  admits  that  many  cases 
arise  where  the  abdominal  route  is  alone  suitable.  He  therefore  gives  both 
methods  fully." — Canada  Lancet. 

D  .     A  P  P  L  E  T  O  N      AND     COMPANY.     NEW     YORK. 


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